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HOW   TO    CARE    FOR    THE 
INSANE 

A   MANUAL    FOR    NURSES 


BY 

WILLIAM  D.  GRANGER,  M.D. 

PROPRIETOR-PHYSICIAN,  VERNON  HOUSE,  MT.  VERNON,  N.  Y. 

FORMERLY   FIRST   ASSISTANT    PHYSICIAN    BUFFALO    STATE    HOSPITAL,    BUFFALO,  N.  Y„ 

MEMBER   AMERICAN  ASSOCIATION  OF  SUPERINTENDENTS   OF   HOSPITALS   FOR 

THE  INSANE.      MEMBER  NEW   YORK  NEUROLOGICAL   SOCIETY. 


SECOND  EDITION.    REVISED. 


G.  P.    PUTNAM'S    SONS 

NEW   YORK  LONDON 

27   WEST  TWENTY-THIRD    ST.        27  KING   WILLIAM    ST.,    STRAND 


Tx  Knickerbocker  ^rcss 
1891 


COPYRIGHT 

G.  P.  PUTNAM'S  SONS 


,  Press  of 
G.  P.  Putnam's  Sons 
New  York    ■ 


NOTE  TO  SECOND  EDITION. 


A  T  the  time  of  starting  a  training  school,  in  1883,  the 
'**■  author  was  unaware  that  like  work  was  commencing 
at  the  McLean  Asylum,  Somerville,  Mass.,  by  Dr.  Camp- 
bell Clark  and  others  in  Scotland,  and  in  New  South 
Wales. 

Each  was  independent,  and  each  worked  out  the  prob- 
lem independently.  Thus,  far  separated  efforts  showed 
the  time  had  come  when  attendants  must  be  evolved  into 
trained  nurses. 

The  most  gratifying  feature  has  been  the  unanimous 
approval  by  American  superintendents  and  the  establish- 
ment of  training  schools  in  almost  every  asylum  in  the 
land,  often  under  the  most  difficult  conditions  and  at  a 
great  sacrifice  of  the  precious  tim.e  and  strength  of  the 
medical  staff. 

The  increasing  number  of  these  schools  and  pupils 
demands  a  second  edition  of  this  little  manual. 

Vernon  House,  Mt.  Vernon,  N.  Y., 
March  21,  i8gi. 


INTRODUCTION. 


'T^HE  writer  began  in  October,  1883,  at  the  Buffalo 
•^  State  Asylum  for  the  Insane,  a  course  of  instruction 
to  the  women  attendants  upon  their  duties  and  how  best 
to  care  for  their  patients.  This  has  been  regularly  con- 
tinued till  it  has  become  a  fixed  part  of  the  asylum  life, 
and  has  developed  into  a  system  of  training,  and  now  a 
class  of  attendants  has  nearly  completed  its  studies. 
Since  July,  1885,  instruction  has  been  given  to  men 
attendants. 

In  April,  1885,  the  Superintendent,  Dr.  J.  B.  Andrews, 
who  had  encouraged  the  school  from  its  conception, 
asked  the  Board  of  Managers  to  officially  recognize  it. 
They  adopted  the  recommendation  and  fixed  the  qualifi- 
cations for  admission,  the  pay  and  privileges  of  its  mem- 
bers, and  provided  for  a  certificate  as  a  trained  nurse 
and  an  attendant  upon  the  insane,  to  be  given  to  all,  who 
at  the  end  of  two  years  successfully  finished  the  full 
course  of  instruction. 

The  writer  believes  that  all  attendants  should  be  regu- 
larly instructed  in  their  duties,  and  the  highest  standard 
of  care  can  be  reached  only  when  this  is  done.  He  also 
believes  that  every  person  who  is  allowed  to  care  for  the 
insane  will  be  greatly  benefited  by  such  instruction,  and 


IV  INTRODUCTION. 

will  be  able  to  learn  every  thing  taught,  if  the  teacher 
uses  simple  methods  and  is  patient  to  instruct. 

As  a  rule  they  enter  upon  the  study  with  interest,  and 
soon  a  skilled  corps  is  formed,  who  are  competent  to  fill 
the  responsible  positions,  and  control  the  unstable  class 
that  drift  in  and  out  of  an  asylum.  Even  the  dullest  are 
awakened  to  new  zeal,  and  are  advanced  to  positions 
of  trust  they  could  .not  otherwise  have  filled. 

A  brief  outline  of  the  course  of  instruction  of  the  school 
may  be  of  interest. 

The  first  year  is  spent  in  learning  the  routine  of  ward 
work  and  filling  minor  positions.  The  attendants  are 
changed  from  ward  to  ward,  and  have  the  care  of  all 
classes  of  the  insane. 

They  first  receive  instruction  in  the  printed  rules  of 
the  asylum.  Every  rule  relating  to  the  duties  of  attend- 
ants is  read  and  explained,  and  special  attention  is  called 
to  the  performance  of  the  following  duties  : 

a.  Duties  to  officers. 

b.  Duties  to  each  other. 

c.  Duties  to  patients. 

d.  Duties  to  the  institution. 

Thus  the  new  attendants  early  get  an  outline  of  their 
duties  in  the  special  care  of  the  insane. 

After  this  comes  instruction  in  elementary  anatomy 
and  physiology.  They  are  taught  of  the  bones,  joints, 
muscles,  and  organs  of  the  body,  food  and  digestion,  the 
circulation  and  respiration,  waste  and  repair,  animal  heat, 
and  the  nervous  system. 

In  order  to  be  ready  for  advanced  instruction  the  ele- 
ments of  physiology  must  be  thoroughly  learned.     The 


IN  TROD  UCTION.  V 

teaching  must  be  adapted  to  the  abihty  and  wants  of 
those  instructed.  Having  fixed  the  limit  of  duties  re- 
quired of  an  attendant,  it  is  easy  to  fix  the  limit  of  in- 
struction. It  is  an  error  to  teach  too  much  medicine,  for 
then  we  begin  to  make  physicians.  All  that  is  needed  is 
attendants  who  are  able  to  do  their  work  intelligently, 
and,  keeping  this  object  in  mind,  lectures  by  a  physician, 
devoid  of  too  much  detail,  but  simple,  direct,  and  plain, 
are  better  than  instruction  from  any  of  the  text-books. 
With  notes  of  the  lectures  furnished,  and  with  repeated 
recitations,  any  lesson  is  readily  learned.  This  way  of 
instructing,  by  lectures,  notes,  and  recitations,  is  con- 
tinued throughout  the  entire  two  years. 

A  course  in  hygiene  follows  the  lectures  in  physiology. 

Instruction  in  these  three  studies  occupies  the  first 
year.  An  attendant  who,  at  the  end  of  this  time,  success- 
fully passes  an  examination  in  them,  and  who  has  been 
faithful  in  his  duties,  is  ready  to  receive  the  advanced  in- 
struction of  the  second  year.  This  includes  the  nursing 
of  the  sick,  the  management  of  emergencies,  and  finally 
the  special  work  of  caring  for  the  insane.  The  wits  of  an 
attendant  upon  the  insane  have  to  be  sharpened  in  many 
directions  not  required  of  a  general  nurse.  The  text- 
books on  nursing  may  properly  be  followed  by  another, 
which  shall  aid  one  skilled  as  a  nurse  to  perform  the 
varied  and  difficult  duties  incident  to  the  care  of  the  in- 
sane and  the  wards  of  an  asylum.  To  furnish  this  is  the 
object. of  this  manual. 

A  brief  review  of  the  physiology  of  the  nervous  system 
is  introduced  for  the  aid  of  students,  in  reading  the  chap- 
ters on  the  mind  and  insanity. 


vi  INTRODUCTION. 

To  teach  any  thing  metaphysical  or  pathological  may 
seem  questionable.  The  class,  however,  has  not  only 
been  interested  in  the  simple  study  of  the  phenomena  of 
the  mind,  but  has  been  able  to  comprehend  and  profit  by 
the  lectures  on  this  subject. 

The  lectures  on  the  care  of  the  insane  were  given  to  the 
class  almost  as  they  appear  in  these  pages.  The  sugges- 
tion was  made  that  if  they  were  printed  they  would  find 
a  place  in  the  hands  of  attendants  in  other  asylums. 
This  is  the  reason  of  their  publication. 

To  my  colleague,  Dr.  A.  W.  Hurd,  I  wish  to  tender  my 
thanks  for  the  valuable  assistance  he  has  given  me  in  the 
preparation  of  this  manual.  I  am  greatly  indebted  to 
Dr.  Andrews  for  his  ever  kind  but  critical  advice.  But 
for  his  encouragement  and  help  neither  the  work  of  in- 
struction nor  the  preparation  of  these  pages  would  have 
been  begun,  nor  success,  if  success  be  gained,  achieved. 


CONTENTS. 


PACK 

Introduction v 

CHAPTER  I. 

The  Nervous  System   and   Some  of  its  More  Import- 
ant Functions i 

Nerve  Centres. — Brain  and  Spinal  Cord„ — The  Nerves. — 
Nerve  Cells  and  Fibres. — Motor  and  Sensory  Nerves. — The 
Five  Organs  of  Special  Sense. — Nerve  Impulses. — The 
Brain  and  Nervous  System  Always  Busy. — Need  of  Rest. 

CHAPTER  II. 

The  Mind  and  Some  of  its  Faculties      .        .        .        .        7 
Mind  and  Matter. — Life. — Relation  of  Mind  and  Brain. — 
Faculties  of  the  Mind. — Intellectual  Faculties. — Will. — 
Emotions. — Instincts. — Moral  Faculties. 

CHAPTER  III. 

Insanity  ;  or,  Disease  of  the  Mind  ....       13 

Insanity  a  Change.  —  Involves  Disease  of  the  Brain. — 
Delusions.  —  Hallucinations.  —  Illusions. — Incoherence.  — 
Mental  States.  —  Mania.  —  Melancholia.  —  Dementia.  — 
Monomania. — Emotional  Insanity. — Dipsomania. — Moral 
Insanity. 


VIU  CONTENTS. 

CHAPTER  IV. 

PAGE 

The  Duties  of  an  Attendant 22 

What  an  Attendant  Should  First  Learn. — The  Relation  of 
Attendants  to  Patients. — The  Character  of  an  Attendant. — 
Relation  to  the  Institution. — How  and  What  to  Observe. 
— Systematized  Plan  of  Observation. — Control  and  Influ- 
ence of  Attendants  over  Patients. — Care  and  Study  of  the 
Individual. — Liberty  to  be  Allowed  Patients. — Self-Control 
of  Patients  to  be  Encouraged. 


CHAPTER  V. 

General  Care  of  the  Insane    .        .         .        .        .        .33 

Reception  of  New  Patients. — Work  and  Employment. — 
Patients'  Care  of  Themselves. — Walking. — Clothing. — 
Bathing. — Serving  of  Food. — Bed  and  Rising  Time. — 
Night  Care. 

CHAPTER  VI. 

Care  of  the  Violent  Insane 45 

Need  of  Studying  Each  Case. — Constant  Attention  and 
Oversight. — Value  of  Employment  and  Out-Door  Exercise. 
— Restriction  and  Idleness. — Paroxysms  of  Violence  ;  How 
Cared  For. — How  to  Hold  or  Carry  a  Patient. — Danger  of 
Injury. — Struggles  to  be  Avoided. — Care  of  Destructive 
Patients. — Use  of  Restraint,  Seclusion,  and  Covered  Bed. 


CHAPTER   VII. 

Care  of  the   Homicidal  and   Suicidal  Insane,  and  of 

Those  Inclined  to  Acts  of  Violence    ...       53 
Dehisions   of    Suspicion. — Homicidal   Patients. — Suicidal 
P.it'enls. — Self- Mutilation. — Incendiary  Patients. 


CONTENTS.  fx 

CHAPTER  VIII. 

PAGE 

Care  of  Some  of  the  Common  Mental  States  and  the 

Accompanying  Bodily  Conditions    .        .        .        .      6o 

Care  in  the  Earlier  Stages. — Insanity  with  Exhaustion. — 
Symptoms  of  Danger. — Care  of  Dementia,  Early  Demen- 
tia, Chronic  or  Terminal  Dementia. — Convalescence. — Re- 
lapse.— Epilepsy. — Paresis. — Care  of  Paralytics,  the  Help- 
less, the  Bed-ridden. — Bed-Sores. 


CHAPTER  IX. 

Some  of  the  Common  Accidents  among  the  Insane,  and 

the  Treatment  of  Emergencies  ....  71 
Certain  Classes  of  Insane  Liable  to  Injury. — Fractures. — 
Wounds. — Bites. — Blows  on  the  Head — Cut  Throat. — 
Wounds  of  the  Extremities  with  Hemorrhage. — Sprains. — 
Choking. — Artificial  Respiration. — Burns. — Frost-bites. — 
States  of  Unconsciousness. — Apoplexy. — Sunstroke. — 
Poisoning. — Eating  Glass. — Injury  with  Needles. 

CHAPTER  X. 

Some  Services    Frequently   Demanded   of  Attendants 

AND  How  to  do  Them 85 

Administration  and  Effects  of  Medicine. — Opium,  Chloral. 
Hyoscine,  and  Hyoscyamine  ;  Doses,  Effects,  Poisoning, 
Treatment. — Stimulants. — Applications  of  Heat  and  Cold. 
— Baths  and  Wet  Packing. — Hypodermic  Injections. — 
Forcible  Feeding  with  Stomach-Tube. — Nutritive  Enemata. 


HOW  TO  CARE  FOR  THE 
INSANE. 


CHAPTER  I. 

THE    NERVOUS   SYSTEM    AND    SOME    OF    ITS   MORE    IMPORT- 
ANT   FUNCTIONS. 

'  I  ^HE  nervous  system  is  made  up  of  a  nerve  centre 
■*•       and  nerves. 

The  great  nerve  centre  is  the  Brain  and  Spinal  Cord. 

The  brain  is  a  body  weighing  about  forty  ounces,  and  fills 
a  cavity  in  the  upper  part  of  the  skull.  The  spinal  cord, 
commonly  called  spinal  marrow,  is  directly  connected 
with  the  brain.  The  skull  rests  upon*the  spinal  column, 
or  backbone,  and  there  is  a  cavity  inside  the  whole 
length  of  this  column,  which  contains  the  cord.  There 
is  an  opening  through  the  base  of  the  skull  where  it  rests 
upon  the  spinal  column,  and  it  is  through  this  opening 
that  the  fibres  of  the  cord  go,  to  pass  into  and  become  a 
part  of  the  brain.  These  most  important  parts  are  care- 
fully protected  by  a  strong  bony  covering. 

Many  nerves  are  given  off  from  the  brain  and  cord  and 
go  practically  everywhere,  so  that  every  part  of  the  body 
is  supplied  with  them.  These  nerves  are  white  cords  of 
different  sizes  ;  the  largest  nerve  of  the  body,  the  one 


2  HOW  TO    CARE  FOR  THE  INSANE. 

that  goes  to  the  leg,  called  the  sciatic,  is  as  large  as  the 
little  finger. 

There  are  really  two  brains  and  two  cords,  as  along  the 
central  line  of  the  body  there  is  a  division  of  the  brain 
and  cord,  making  two  halves  exactly  alike.  These  halves 
are  connected  together,  the  division  not  being  complete. 

Nerves  are  given  off  in  pairs ;  for  example,  from  either 
side  of  the  brain  arises  a  nerve  that  goes  to  each  eye.  So 
two  nerves  exactly  alike  spring  from  the  two  sides  of  the 
spinal  cord,  going  to  each  arm. 

A  nerve  is  composed  of  a  bundle  of  fibres,  microscopic 
in  size.  As  a  nerve  passes  to  the  extremities  it  divides 
by  branching  much  as  does  an  artery,  and  thus  a  bundle 
of  fibres  is  distributed  to  a  muscle,  or  a  part  of  the  skin, 
or  to  an  organ,  and  every  part  of  the  body  has  a  direct 
nerve  supply,  much  as  you  saw  in  the  microscope  it  was 
supplied  with  blood  by  means  of  the  capillaries.  We 
cannot  prick  our  finger  with  the  finest  needle  but  nerve 
fibres  are  irritated,  and  we  feel  it,  and  capillaries  are  in- 
jured and  we  get  a  drop  of  blood. 

Most  of  the  nerves  that  go  to  the  arms,  legs,  and  organs 
of  the  chest  and  abdomen,  arise  in  and  proceed  from  the 
spinal  cord,  but  some  of  the  fibres  begin  in  the  brain  and 
are  continued  down  the  cord,  where,  joining  with  fibres 
that  originate  in  the  cord  itself,  both  go  to  make  up  the 
nerve,  thus  connecting  all  parts  of  the  body  with  the 
great  centre. 

The  brain  and  cord  are  made  up  of  blood-vessels, 
nerve  cells,  nerve  fibres,  and,  holding  them  all  together, 
connective  tissue.  The  cells  are  very  small,  being  micro- 
scopic in  size  ;  there  are  an  immense  number  of  them. 


THE   NERVOUS   SYSTEM.  3 

and  they  make  up  most  of  the  gray  matter  or  outside  of 
the  brain,  but  in  the  spinal  cord  the  gray  matter  is  in  the 
centre.  The  fibres  that  go  to  make  up  the  nerves  begin 
and  spring  from  the  cells,  and  they  also  unite  them 
together. 

The  cells  are  gathered  into  groups,  which  have  each  a 
separate  function  to  perform.  There  is  a  group  from 
which  the  nerve  of  the  eye  proceeds  ;  another  for  the 
nerve  that  goes  to  the  ear  ;  another  for  the  nerve  that 
goes  to  the  arm  ;  and  another  for  the  nerve  of  the  heart. 
There  is  a  group  that  presides  over  speech,  and  other 
groups  that  preside  over  mental  action,  while  all  of  these 
are  connected  together  by  fibres.  Thus  it  appears  that 
the  brain  is  a  true  '"'  centre,"  and  the  nerves  but  the 
means  of  connection  between  different  parts  of  the  body 
and  the  brain,  and  also  between  different  parts  of  the 
brain. 

Nerves  have  two  special  functions  :  one  to  carry  im- 
pressions made  upon  the  fibres,  that  end  in  the  different 
parts  and  organs  of  the  body,  to  the  brain  ;  another  to 
carry  from  the  nerve  cells  so-called  "  nerve  impulses,"  to 
the  different  parts  and  organs  of  the  body.  Some  nerves 
have  in  themselves  these  two  functions,  as  the  nerves 
that  go  to  the  arm  or  leg  ;  others  have  but  one,  as  the 
optic  or  eye  nerve,  which  can  only  carry  the  sensation  of 
sight  from  the  eye  to  the  brain. 

The  nerves  that  carry  sensations  to  the  brain  are  called 
Sensory-  Nerves.  The  nerves  that  carry  motor  impulses 
from  the  brain  are  called  Motor  N'erves. 

There  are  five  special  organs  of  sense,  each  receiving 
different  impressions,  and  sending  by  its  sensory  nerve  or 


4  HOW  TO    CARE   FOR  THE   INSANE. 

nerves  a  different  character  of  sensation  to  the  brain, 
namely  : 

The  eye,  giving  sensations  of  light  and  color. 

The  ear,  giving  sensations  of  sound. 

The  nose,  giving  sensations  of  smell. 

The  mouth,  giving  sensations  of  taste. 

The  skin,  giving  sensations  of  touch,  with  ideas  of 
roughness,  smoothness,  hardness,  softness,  heat,  and  cold. 

There  must  be,  in  every  case,  a  direct  nerve  connec- 
tion from  the  organ  of  special  sense  to  the  special  group 
of  cells  in  the  brain  to  which  the  nerve  goes.  If  the 
connection  is  broken  at  any  point,  the  impression  made 
upon  the  fibres  in  the  organ  of  sense  cannot  reach  the 
brain.  Only  after  the  impression  reaches  the  brain 
and  the  cells  are  affected,  do  we  become  conscious  of  a 
sensation.  We  then  say,  as  the  case  may  be,  I  see,  or 
hear,  or  smell,  or  taste,  or  feel  something. 

It  thus  appears  that  these  organs  of  sense  simply  re- 
ceive the  impressions  made  upon  them  to  transmit  to  the 
brain,  and  it  is  really  the  brain  that  sees,  hears,  smells, 
tastes,  and  feels.  By  the  action  of  the  organs  and  nerves 
of  special  sense  we  get  all  our  knowledge  of  the  external 
world,  and,  probably,  if  we  had  no  organs  of  sense,  we 
would  have  no  consciousness  of  our  existence. 

Pain  is  due  to  abnormal  action  of  sensory  nerves, 
caused  by  disease,  injury,  or  pressure,  and  the  irritation 
made,  being  carried  to  the  brain  makes  us  conscious  of 
the  peculiar  sensation  we  call  pain.  So  the  want  of  food 
or  water  makes  an  impression  upon  nerves,  which  being 
carried  to  the  brain  causes  a  peculiar  sensation,  and  we 
say  we  feel  hungry  or  thirsty. 


THE  NERVOUS   SYSTEM.  5 

The  Motor  Nerves  arise  in  the  cells  of  the  brain  and 
cord.  Those  which  go  to  the  voluntary  muscles  cause 
them  to  contract,  and  are  under  the  control  of  the  will. 
If  the  cells  are  diseased,  if  they  do  not  get  enough  ar- 
terial blood,  or  are  poisoned  by  carbonic  acid,  or  if  the 
nerves  are  diseased,  injured,  or  cut,  so  that  nerve  im- 
pulses cannot  be  sent  from  the  brain  to  the  muscles, 
we.  have  paralysis  of  a  muscle  or  a  group  of  muscles, 
according  to  the  extent  of  the  injury.  Now  we  can  ap- 
preciate the  force  of  this  teaching  in  the  physiology  of 
the  muscular  system,  that  ''  paralysis  is  a  loss  of  power, 
either  partial  or  complete,  to  contract  muscles,  due  to 
disease  of  the  nerves." 

By  the  ready  action  of  our  mind,  the  quick  working  of 
our  will,  we  direct  and  control  the  action  of  our  muscles, 
so  as  to  perform  with  the  utmost  skill  and  ease  the  varied 
and  innumerable  movements  of  our  body. 

It  seems  very  easy  to  do  this,  but  watch  a  child  learn- 
ing to  walk  ;  it  is  educating  its  mind  and  will  to  control 
the  muscles,  and  it  is  a  slow  and  difficult  education. 

But  all  motor  impulses  and  bodily  activities  are  not 
under  the  control  of  the  will.  The  heart  is  supplied  with 
motor  nerves,  but  we  cannot  by  our  will  stop  its  beating 
or  control  its  action.  The  taking  of  food  makes  a  mental 
impression,  and  without  the  will  being  involved,  impulses 
are  sent  to  the  glands  of  the  mouth,  setting  them  actively 
at  work,  and  saliva  flows.  So  the  stomach  begins  to 
churn  food  when  it  is  introduced,  and  the  liver  is  kept  at 
work  making  bile  and  sugar,  and  we  breathe  when  we  are 
asleep. 

All   the  organs  of  the  body  are  supplied  with  motor 


6  HOW  TO   CARE  FOR  THE  INSANE. 

nerves,  that  regulate  their  action  and  give  them  the 
power  to  do  their  function  or  work,  but  with  the  exception 
of  the  muscles,  this  power  is  sent  without  the  action  of 
the  will. 

Our  brains  aie  very  busy.  While  we  are  awake  we  are 
constantly  receiving  sensations,  we  are  thinking,  remem- 
bering, willing,  and  sending  many  messages  every  minute, 
and  directing  power  to  all  parts  of  the  body.  The  brain 
works  and  gets  tired,  just  as  the  rest  of  the  body  gets 
tired,  and,  if  abused,  injured,  or  overworked,  may  become 
diseased  as  may  any  part.  Its  tissues  wear  out,  are 
burned  up,  and  require  the  same  supply  of  material  to 
repair  them  that  any  other  part  of  the  body  requires.  It 
needs  then  rest,  good  food,  good  blood,  and  plenty  of 
oxygen. 

No  wonder  some  brains  give  out,  and  fail  to  do  their 
work  properly,  and  so  cause  insanity. 


CHAPTER    II. 

THE    MIND    AND    SOME    OF    ITS   FACULTIES. 

"^  1  7"  E  know  there  is  something  we  call  mind,  because 
^  ^  we  know  something  of  its  way  of  working,  or 
its  faculties.  What  mind  is  we  do  not  know,  but  we  know  it 
is  not  matter,  because  matter  is  something  that  occupies 
space,  and  has  qualities  that  do  not  belong  to  mind.  We  say 
of  mind,  it  reasons,  remembers,  or  wills  ;  of  matter,  that 
it  is  hard  or  soft,  or  cold  or  elastic,  or  that  it  has  color  ; 
speaking  always  of  the  faculties  of  mind  or  what  it  does, 
and  of  the  qualities  of  matter,  or  what  it  is.  We  do 
not  know  what  matter  is,  only  how  it  appears  to  us  ;  we 
know  it  is  not  mind  because  mind  is  something  spiritual, 
and  possessed  of  faculties  or  powers  that  do  not  belong 
to  matter. 

Mind  and  Matter  are  the  only  forms  of  existence  of 
which  we  have  any  knowledge. 

We  speak  of  matter  as  inorganic — that  is,  without  life, 
as  iron,  water,  oxygen  ;  and  as  organic,  or  matter  plus 
something  we  call  life.  Life  appears  in  two  forms, 
namely,  vegetable  and  animal.  The  lowest  forms  of 
animal  life  have  no  nervous  system,  but  as  we  ascend  in 
the  scale  the  nervous  system  appears,  and  becomes  more 
and  more  complete. 

Man  possesses  the  most  perfect  nervous   system,  has 

7 


8  HOW  TO   CARE  FOR  THE  INSANE. 

the  most  perfect  brain,  and  also  an  intelligence  far  above 
that  of  any  other  animal,  and  is  endowed  with  some 
mental  faculties  that  belong  to  him  alone.  The  brain 
may  be  said  to  be  the  organ  of  the  mind,  but  we  do  not 
know  what  is  the  true  relation  between  them  ;  that  is, 
how  the  brain  is  acted  upon  by  the  mind,  or  how  the 
action  of  the  mind  affects  the  brain.  Brain  is  matter, 
and  very  solid  matter  as  well,  mind  is  immaterial,  or 
spiritual,  and  the  exact  connection  between  something 
material  and  something  spiritual  has  never  been  made 
out  and  never  will  be. 

Some  say  the  brain  makes  mind  a  good  deal  as  liver 
makes  bile,  or  the  glands  of  the  mouth  make  saliva,  or 
the  cells  of  the  brain  make  motor  impulses,  and  if  the 
brain  does  not  act  there  is  no  mind  made  ;  so  much  cell 
action,  so  much  memory,  reason,  or  will  produced.  But 
how,  it  is  immediately  asked,  is  something  material  to 
make  something  immaterial  ?  Others  say  that  mind  is 
something,  and  has  an  existence  of  its  own,  and,  though 
spiritual,  acts  upon  its  organ,  the  brain,  and  by  so  doing, 
we  are  conscious  that  we  see,  reason,  remember,  and  will. 
But  how,  it  is  immediately  asked,  does  something  imma- 
terial act  upon  something  material  ?  We  do  not  know, 
and  we  probably  never  shall  know.  This  intimate  connec- 
tion between  mind  and  matter  exists  during  life  only  ;  it 
begins  with  life  and  ends  with  life. 

We  must  then  come  back  to  the  starting-point — there 
are  two  forms  of  existence,  mind  and  matter.  We  do  not 
know  what  either  really  ic,  but  only  the  faculties  or 
working  of  our  minds,  and  the  qualities  or  appearance  of 
matter. 


THE   MIND  AND   SOME   OF  ITS  FACULTIES.        9 

Mind  thinks  or  remembers,  reasons  or  wills,  but  these 
are  faculties  of  the  mind  ;  it  is  what  the  mind  does,  not 
mind  itself.  Gold  is  yellow,  but  yellow  is  not  gold  ;  gold 
is  hard,  but  hardness  is  not  gold  ;  these  are  qualities  of 
gold,  and  not  gold  itself. 

In  the  study  of  physiology  you  found  the  body  divided 
into  many  parts,  and  that  these  parts  had  each  a  separate 
function  or  duty  to  perform.  In  the  study  of  the  mind, 
we  find  it  has  many  different  faculties  or  ways  of  working. 
We  did  not  study  all  the  functions  of  the  body,  so  we 
will  not  study  all  the  faculties  of  the  mind. 

The  mind  is  very  complicated  in  its  action,  and  diffi- 
cult to  understand.  Men  study  it  all  their  lives  and  are 
not  agreed  about  some  of  its  simple  manifestations,  and 
argue  and  even  contend  about  their  differences.  There 
are,  however,  some  seemingly  natural  divisions  of  the 
faculties  of  the  mind,  and  a  knowledge  of  these  is 
sufficient  for  our  purposes. 

We  may  say  of  the  mind  that  it  possesses  : 

a.  Intellectual  faculties. 

b.  Will. 

c.  Emotions  or  feelings. 

d.  Instincts. 

e.  Moral  faculties  or  conscience. 

The  first  three  are  commonly  given  as  divisions  of  the 
mind ;  the  last  two  are  included  for  convenience  of 
teaching. 

The  Intellectual  Faculties  include  those  powers  which 
in  common  language  are  called  "mind."  A  few  only 
will  be  considered — namely,  the  perceptive  faculty,  con- 
sciousness, memory,  and  reason. 


lO         ^       HOW  TO    CARE  FOR  THE  INSANE. 

The  Perceptive  Faculty  is  the  power  of  the  mind  to 
perceive  or  know  the  sensations  brought  to  the  brain  by 
the  sensory  nerves,  from  the  organs  of  sense,  and  the 
action  of  this  faculty  gives  us  a  knowledge  of  the  exist- 
ence and  qualities  of  matter. 

Consciousness  is  that  faculty  by  which  we  knov/  v/e  per- 
ceive, reason,  remember,  will,  or  possess  emotions.  By 
its  operation  we  know  that  we  exist,  have  a  mind,  and  what 
that  mind  does. 

Memory  is  that  faculty  by  which  we  are  able  to  recall 
to  consciousness  the  knowledge  we  possess  of  past  events. 

Reason  is  that  faculty  by  which  we  are  able  to  make 
use  of  what  we  know  and  to  acquire  new  knowledge. 
For  instance,  I  know  the  distance  between  two  places  is 
sixty  miles,  and  I  know  that  the  cars,  going  between  the 
places,  travel  at  the  rate  of  twenty  miles  an  hour,  and  that 
they  leave  at  four  o'clock.  Without  reason,  I  could 
never  of  myself,  know  the  two  new  facts,  that  it  would 
require  three  hours  to  make  the  journey,  and  that  the 
arrival  will  be  at  seven  o'clock.  The  faculty  of  reason 
is  one  of  the  most  distinctive  of  the  human  mind. 

The  Will. — In  consequence  of  our  perceptions,  our 
consciousness,  our  memory,  our  reason,  we  are  in  a  con- 
dition to  know  a  good  deal  of  what  is  about  us,  and  of 
ourselves,  and  we  desire  to  bring  ourselves  into  relation 
with  the  outside  world,  and  therefore  we  act.  There  is 
a  faculty  of  mind  that  allows  us  to  choose  how  to  act, 
and  this  is  called  the  will,  or  that  faculty  of  the  mind 
"by  which  we  are  capable  of  choosing."  By  the  action 
of  the  will,  we  direct  and  control  the  voluntary  muscles 
and  motions  of  the  body,  while  the  action  of  the  mind  is 
also  largely  under  its  control. 


THE  MIND  AND    SOME    OF  ITS  FACULTIES.      II 

It  may  truly  be  said  that  unless  we  are  under  the  com- 
pulsion of  some  physical  force,  we  always  choose  to  do 
whatever  we  most  wish  to  do.  This  liberty  of  choosing 
is  called  "freedom  of  the  will,"  and  because  we  are  free 
to  choose,  we  are  responsible  for  the  consequences  of  our 
choice.  We  say,  in  common  language,  a  person  is  re- 
sponsible for  what  he  does,  and  both  human  and  divine 
law  holds  each  to  a  strict  accountability  for  his  conduct, 
because  all  are  free  to  choose  how  they  will  conduct 
themselves. 

The  Emotions  or  Feelings. — The  emotions  are  joy,  love, 
grief,  hatred,  anger,  jealousy,  and  other  like  conditions, 
and  we  speak  of  them  as  "  natural,"  because  they  appear 
without  the  operation  of  our  intellect  or  will,  and  the 
capacity  for  them  seems  to  be  a  part  of  our  existence. 
They  should,  however,  be  under  the  control  of  reason 
and  will,  and  a  person  who  gives  way  to  his  feelings,  as 
of  jealousy,  and  murders,  is  held  responsible  by  human 
and  divine  law.  But  though  we  control  them,  we  cannot 
prevent  their  action,  and  we  must,  as  long  as  we  live,  feel 
love  and  joy,  be  affected  by  grief,  suffer  from  anger,  or 
be  jealous. 

Instincts. — These  belong  largely  to  our  animal  nature  ; 
our  appetites  and  desires  are  instincts,  and  we  speak  of 
them  as  "  natural."  Children  want  food  and  drink  before 
they  know  what  it  is  they  want,  and  birds  in  the  nest, 
open  their  little  mouths  for  the  worm  their  mother  < 
brings  them. 

Appetites  indulged  in  become  strong,  and  are  often 
uncontrolled  by  the  reason  and  will ;  as  the  indulged 
appetite  for  liquor.     A  strong  and  healthy  mind  should 


12  HOW  TO    CARE   FOR   THE   TV  SANE. 

control  the  appetites,  as  we  have  learned  it  should  con- 
trol the  emotions,  and  we  are  justly  held  responsible  for 
the  consequences  of  an  indulged  appetite. 

Moral  Faculties, — There  exists  in  the  mind  of  man  a 
knowledge  of  right  and  wrong,  and  a  feeling  of  obliga- 
tion to  respect  the  rights  of  others.  AVe  can  hardly  con- 
ceive of  a  man  in  his  ris^ht  mind  who  does  not  know  it  is 
wrong  to  lie,  or  steal,  or  murder.  The  capacity  to  know 
right  from  wrong  is  called  conscience. 

Most  people,  perhaps  all,  have  a  feeling  of  relation  and 
obligation  to  a  higher  moral  being  than  man.  The  feel- 
ing to  do  right  because  it  is  pleasing  to  a  God  to  whom 
we  are  directly  responsible,  is  the  foundation  of  our 
religious  convictions. 

The  mind  is  a  most  complex  affair,  it  is  always  active, 
nor  is  one  faculty  at  work  and  the  rest  idle,  but  many 
parts  are  at  work  at  the  same  time,  and  act  and  react 
upon  each  other.  We  may  exercise  our  perceptive 
faculty,  or  reason,  memory,  and  will,  and  be  affected  by 
our  feelings  at  the  same  time.  There  is  with  it  all  a 
regulating  power  that  coordinates  or  brings  these  differ- 
ent actions  into  harmony,  and  we  get  the  working  of  a 
healthv  mind. 


CHAPTER  III. 

INSANITY  ;    OR,  DISEASE  OF  THE    MIND. 

T  N  common  language  we  speak  of  the  mind  diseased. 
This  is  not  strictly  true,  as  it  is  the  brain  that  is  dis- 
eased and,  in  consequence,  we  get  disturbed  mental  action. 

Every  person  has  individual  characteristics.  As  no  two 
faces  are  alike,  so  the  mind,  character,  and  manner  of 
no  two  are  alike,  and  it  is  by  the  manifestation  of  these, 
that  each  is  known. 

When  a  person  becomes  insane  there  is  always  a  change 
from  his  natural  way  of  thinking,  feeling,  and  acting,  due 
to  disease  of  the  brain.  Sometimes  the  change  is  slight, 
or  concealed  by  the  patient,  and  is  apparent  only  to  near 
friends,  or  after  a  careful  examination.  Sometimes  it  is 
so  great  as  to  attract  immediate  attention,  when  it  may 
present  the  features  of  raving  madness,  or  of  the  most 
abject  melancholy. 

To  illustrate  this  change,  we  may  suppose  both  a  king 
and  a  pauper  to  become  insane  :  there  is,  of  course,  a 
vast  difference  between  them,  but  the  king  may  be  so 
changed  by  the  disease  as  to  believe  that  he  is  a  pauper, 
and  himself  and  his  family  starving,  and  he  may  also  wish 
and  even  try  to  work  and  dig  like  a  laborer  to  support 
them  ;  or  a  pauper  may  think  himself  a  king,  and  try  to 
act  like  one.     Such  conditions  show  a  marked  change  in 

13 


14  HOW  TO    CARE  FOR  THE  INSANE. 

the  manner  of  thinking,  feeling,  and  acting,  which  in- 
volves diseased  action  of  the  intellect,  the  emotions,  and 
the  will. 

Sometimes  the  appetites  are  also  changed,  or  control 
over  them  is  lost,  and  sometimes  the  moral  nature  is  af- 
fected as  well,  sometimes  a  single  faculty  of  the  mind 
appears  more  disturbed  than  do  others  ;  it  is,  however, 
doubtful,  or  at  least  denied,  that  one  faculty  can  show 
such  disturbed  mental  action  as  to  indicate  insanity,  and 
the  rest  of  the  mind  appear  perfectly  healthy  and  normal. 
With  the  changes  that  have  been  spoken  of,  there  is  gen- 
erally disturbances  of  the  physical  health,  and  often  of  a 
marked  character.  It  must  be  rem.embered  that  mere 
oddity  of  appearance  or  eccentricity  of  conduct,  however 
marked,  if  natural,  do  not  of  themselves  constitute  signs 
of  insanity. 

Some  Mental  Symptoms  of  Insanity. — There  are  some 
important  mental  symptoms  which  quite  generally  ac- 
company insanity,  and  are  found  either  alone  or  com- 
bined in  the  individual  case.     These  are  : 

a.  Delusions. 

h.  Hallucinations. 

c.  Illusions. 

d.  Incoherence  of  speech. 

Delusions  are  false  beliefs.  We  think  a  belief  in  the 
religion  of  Mahomet  is  a  delusion,  but  not  an  insane  one. 
Insane  delusions  arise  from  disease  of  the  brain,  and  are 
a  part  of  those  mental  changes  that  appear  during  its 
progress.  The  king,  who,  under  the  influence  of  disease, 
thinks  himself  a  pauper  and  that  he  and  his  family  are 
starving,  and  the  pauper,  who  thinks  himself  a  king,  v/ith 


INSANITY.  15 

all  the  wealth  and  power  of  one,   have  each  insane  de- 
lusions. 

Some  delusions  are  fleeting  and  changeable,  lasting  a 
few  days,  weeks,  or  months,  while  others  are  fixed,  lasting 
a  lifetime  ;  some  are  impossible  and  beyond  rational  be- 
lief, as  when  a  man  thinks  himself  Queen  Victoria,  or 
that  his  head  is  made  of  brass,  or  that  he  is  dead,  and  yet 
sleeps  and  eats  and  talks  ;  other  delusions  are  possible, 
as  when  a  king  thinks  himself  a  pauper,  because  such  a 
thing  may  and  even  has  happened,  or  when  a  pauper 
thinks  himself  a  king,  because  people  of  very  low  degree 
have  risen  to  such  a  station,  but  they  are  very  improbable, 
and  we  do  not  expect  such  things  among  Americans, 
much  less  among  our  patients.  Other  delusions  are  not 
only  possible,  but  relate  to  things  that  may  or  do  happen, 
or  are  within  the  bounds  of  a  rational  belief,  as  that  of  a 
person  who  insists  he  has  a  cancer,  or  that  he  has  com- 
mitted the  unpardonable  sin,  or  that  poverty  is  impend- 
ing and  the  poorhouse  not  far  off ;  or  that  of  a  woman 
that  she  has  been  violated,  or  that,  when  her  child  was 
sick  she  so  neglected  it,  that  it  died.  Such  beliefs  as 
these  are  delusions,  when  they  have  no  other  reason  for 
their  existence  than  that  they  are  caused  by  disease. 

Some  delusions  are  called  homicidal,  suicidal,  or  dan- 
gerous, because  they  cause  a  patient  to  do,  or  want  to  do, 
acts  that  are  dangerous  to  himself  or  others,  or  property. 

Hallucinations. — When  a  patient  has  hallucinations,  he 
thinks  he  sees,  hears,  smells,  tastes,  or  feels  something, 
when  there  is  really  nothing  to  cause  the  sensations  or 
ideas  except  diseased  action  of  the  brain  ;  nothing  being 
sent  to  the  brain  from   any  special  organ  of  sensC;,  he 


l6  HOW  TO   CARE  FOR  THE   INSANE. 

really  sees,  hears,  smells,  tastes,  or  feels  nothing,  it  is  all 
imagination,  though  seemingly  very  real. 

For  instance,  a  person  thinks  he  hears  a  voice,  perhaps 
that  of  God,  or  of  some  one  who  is  dead,  or  of  an  absent 
friend,  or  thinks  he  sees  these  persons,  when  there  is 
nothing  external  to  the  brain  to  excite  the  sensation  or 
give  the  idea. 

Illusions. — When  illusions  are  present,  the  mind  fails  to 
perceive  correctly  what  the  eye  sees,  or  the  ear  hears,  or 
the  impressions  that  are  brought  to  the  brain  from  any 
of  the  organs  of  sense.  For  instance,  a  person  looks  at 
a  row  of  trees,  and  they  appear  to  him  to  be  a  row  of 
soldiers  ;  or  the  whistle  of  a  locomotive  may  be  so  changed 
as  to  seem  to  be  the  voice  of  God  ;  or  the  odor  of  a  rose, 
burning  sulphur  ;  food  may  taste  like  poison,  or  the  hand 
of  a  friend  feel  like  a  piece  of  ice  or  a  red-hot  iron,  and 
is  so  believed  to  be.     These  are  deceptions  of  the  senses. 

In  insanity,  the  truth  and  existence  of  delusions,  hal- 
lucinations, and  illusions  are  fully  believed  in,  and  the 
patient  cannot  be  argued  out  of  the  belief,  however  ab- 
surd or  unreal  it  may  be. 

Incoherence  of  Speech. — When  a  person  is  incoherent, 
he  rambles  in  talk  ;  there  is  little  connection  between 
different  sentences,  or  the  sentence  itself  is  meaningless, 
being  a  mere  jumble  of  words  ;  sometimes  ideas  come  too 
rapidly  into  the  mind,  and  some  new  subject  is  begun 
and  talked  about  before  the  first  is  finished  ;  sometimes 
the  mind  is  slow,  and  memory  forgets  what  is  being 
talked  about. 

General  States  of  Insanity. — There  are  a  few  general 
mental   states  in   insanity,   one   of  which  being  present 


INSANITY.  17 

gives   the  character  and  name    to    the    disease.     These 
are  : 

a.  A  state  of  exaltation  of  mind,  or  mania. 

b.  A  state  of  depression  of  mind^,  or  melancholia. 

c.  A  state  of  enf  eeblement  of  mind,  or  dementia. 

But  one  of  these  first  two  states  of  feeling  can  be  pres- 
ent at  the  same  time,  for  a  person  cannot  at  any  one  mo- 
ment be  both  exalted  and  depressed,  though  he  have 
mania  to  day,  and  afterward  be  so  changed  in  his  feeling 
as  to  have  melancholia  to-morrow,  or  next  week,  or  next 
month. 

In  a  general  way  all  disease  is  divided  into  acute  and 
chronic  forms.  An  acute  disease  is  one  of  recent  origin, 
and  from  which  recovery  is  to  be  hoped  for  ;  a  chronic 
disease  is  prolonged  and  does  not  tend  to  recovery  ;  an 
acute  disease  may  become  chronic. 

Mania  and  melancholia  are  at  first  considered  acute 
and  curable,  but,  if  recovery  does  not  take  place,  they 
pass  into  either  chronic  mania  or  chronic  melancholia, 
or,  if  the  mind  is  much  enfeebled,  into  a  condition  of 
dementia. 

Mania. — In  mania  the  mind  is  generally  very  active, 
though  lacking  in  control,  and  is  irregular  and  illogical 
in  its  action  ;  the  patient  talks  rapidly,  and  upon  many 
subjects,  and  is  often  incoherent,  or  he  laughs,  sings, 
dances,  or  cries,  perhaps  in  turn  ;  he  is  often  irritable 
and  unreasonable,  and  perhaps  threatening,  and  becomes 
more  violent  if  interfered  with. 

Accompanying  this  mental  excitement  there  is  fre- 
quently persistent  loss  of  sleep,  constant  restlessness,  and 
great  bodily  activity,    and  indifference  to  or  refusal  of 


1 8  HOW  TO   CARE  FOR  THE  INSANE. 

food.  Sometimes  the  brain  excitement  is  so  great  that  all 
self-control  is  lost,  and  the  patient  becomes  a  raving 
maniac. 

The  delusions  of  mania  are  largely  of  grandeur  and 
self-exaltation  ;  the  patient  thinks  himself  in  the  best  of 
health,  and  very  strong,  or  of  a  superior  mind,  or,  that 
he  is  a  great  singer,  poet,  actor,  or  preacher ;  perhaps, 
taking  a  higher  flight,  he  thinks  himself  possessed  of  the 
wealth  of  Vanderbilt,  or  that  he  is  the  Pope,  or  the  Presi- 
dent, or  even  God  himself. 

Sometimes  the  excitement  comes  on  in  paroxysms,  last- 
ing a  few  days  or  weeks,  with  periods,  more  or  less  pro- 
longed, of  comparative  mental  quiet. 

Melancholia. — In  melancholia  the  expression  of  the 
face  often  tells  the  character  of  the  disease  ;  the  eyes  are 
downcast,  the  lines  of  the  face  are  lengthened,  and  the 
whole  appearance  is  that  of  unhappiness. 

In  this  form  of  insanity  the  patient  may  refuse  to  speak 
or  interest  himself  in  any  thing,  or  he  may  moan,  groan  and 
cry,  and  walk  back  and  forth  wringing  his  hands  ;  when 
he  is  quiet,  the  mind,  however,  may  be  very  active  and  full 
of  delusions,  which  occupy  it  to  the  exclusion  of  every 
thing,  driving  away  sleep,  and  making  him  indifferent  to 
the  taking  of  food  or  attending  to  his  most  necessary 
wants  ;  sometimes  the  patient  talks  a  great  deal,  but  al- 
ways about  his  delusions,  which  are  generally  connected 
with  himself,  his  family,  or  his  affairs. 

Melancholiacs  are  often  tortured  by  fears,  and,  there- 
fore, become  frenzied  and  as  wild  and  violent  as  in 
mania  ;  or  they  may  be  very  suspicious,  thinking  that 
some  one  is  persecuting  them,  or  poisoning  their  food,  or 


INSANITY.  19 

following  to  kill  them.  On  account  of  their  delusions 
they  frequently  refuse  food,  they  generally  sleep  poorly, 
and  are  often  very  suicidal. 

Dementia. — This  form  of  insanity  is  most  frequently 
the  result  of  acute  mania  or  melancholia,  and  comes  after 
the  force  and  intensity  of  the  disease  has  spent  itself, 
leaving  the  mind  crippled  and  weakened.  The  percep- 
tions are  blunted  and  distorted,  memory  fails,  the  reason- 
ing powers  are  weakened,  the  will  has  ceased  to  control, 
the  emotions  and  appetites  are  dormant  or  changed,  and 
the  mind  may  become  almost  a  blank,  though  in  the 
narrow  circle  of  thought  there  is  left  remains  of  delu- 
sions, illusions,  and  hallucinations.  The  patient  is 
frequently  careless  of  the  ordinary  necessities  and  de- 
cencies of  life,  and  requires  constant  care. 

There  are  degrees  of  dementia  :  it  may  be  slight,  par- 
tial, or  nearly  complete.  During  the  first  few  months  or 
years  dementia  often  ends  in  recovery,  but,  as  it  con- 
tinues, the  case  becomes  more  and  more  hopeless. 

Monomania. — This  is  a  term  belonging  to  common 
speech,  but  there  is  not  an  agreement  of  opinion  as  to 
the  existence  of  such  a  special  form  of  insanity,  nor 
among  those  who  believe  in  it,  as  to  what  it  is  and  what 
are  its  symptoms. 

Monomania  really  means  an  insanity  with  but  one, 
or,  at  most,  a  small  class  of  delusions  of  the  same  char- 
acter, the  rest  of  the  mind  showing  no  disease.  Hardly 
any  one  believes  in  the  existence  of  such  a  narrow  limit 
to  insanity,  and,  getting  beyond  this  point,  there  is  no 
agreement  where  the  limit  should  be  set  up  to  mark  and 
bound  it. 


20  HOW  TO   CARE  FOR  THE  INSANE. 

Some  think  there  is  a  special  insanity  of  the  emotions 
only,  and  call  it  "  emotional  insanity."  There  is  not  an 
agreement  of  opinion  as  to  what  emotional  insanity  is  ; 
the  idea  seems  to  be  that  the  emotions,  or  one  of  them, 
so  overpower  reason  and  will  as  to  make  the  person 
irresponsible.  This  condition  is  supposed  to  exist  with- 
out disturbances  of  the  intellectual  faculties,  and  to  be 
unaccompanied  by  delusions,  hallucinations,  or  illusions. 
Others  see  in  these  cases  no  evidence  of  insanity  ;  noth- 
ing but  over-indulgence  of  the  emotions,  or  a  want  of 
exercise  of  self-control,  or  an  excuse  for  crime. 

Some  persons  believe  that  the  appetites  over-indulged 
become  morbid  and  produce  disease  of  the  nervous  sys- 
tem, and  as  a  consequence  the  reason  and  will  are 
weakened  in  relation  to  this  indulged  appetite,  and  the 
opinion  is  reached  that  it  is  a  form  of  insanity.  An  in- 
dulged appetite  for  drink  is  called  dipsomania.  Others 
believe  that  unless  there  are  present  the  usual  symptoms, 
associated  as  they  generally  appear  in  insanity,  these 
cases  are  nothing  but  unbridled  appetites  or  vices. 

Moral  Insanity. — There  are  those  who  claim  that  the 
moral  nature  alone  may  be  diseased,  and  the  persons  in 
whom  this  occurs  are  said  to  lose  the  appreciation  of 
right  and  wrong,  or  have  an  uncontrollable  propensity  to 
do  some  wrong  act,  and  take  a  peculiar  pleasure  in  so 
doing.  Special  names  are  given  to  these  acts,  according 
to  their  character,  as  "  kleptomania,  an  impulse  that 
prompts  to  steal "  ;  or  "  pyromania,  love  of  setting 
things  on  fire  "  ;  or  *'  homicidal  mania,  an  intense  desire 
to  kill."  Other  persons  considering  these  cases  and  find- 
ing no  delusions,  or  intellectual  disturbances,  or  change 


INSANITY.  21 

in  feeling,  thinking,  or  acting  due  to  disease,  call  the 
condition  one  of  crime  only. 

These  are  difficult  matters  to  understand,  and  those 
who  make  a  life-study  of  insanity  do  not  fully  understand 
them,  or  agree  together  as  to  what  they  know.  They 
are,  however,  terms  of  common  speech,  and  it  is  well 
to  have  some  idea  of  them,  as  it  will  add  interest  to  the 
study  of  the  patients  under  care  and  charge. 


CHAPTER   IV. 

THE    DUTIES    OF    AN    ATTENDANT. 

JJZHA  Tan  Attendant  Should  First  Learn. — The  duties 
of  an  attendant  upon  the  insane  are  varied,  ardu- 
ous, and  exacting  ;  they  are  associated  with  irritations, 
perplexities,  and  anxieties,  bring  grave  responsibilities, 
and  call  for  the  exercise  of  tact,  judgment,  and  self- 
control. 

These  many  duties  are  not  quickly  nor  easily  learned, 
and  the  new  attendant  must  be  willing  to  fill,  at  first,  a 
minor  position,  to  begin  at  the  beginning  and  learn  grad- 
ually all  the  details  of  ward  work  ;  he  must  acquire  habits 
of  caution  and  watchfulness,  and  learn  in  a  general  way 
the  care  of  the  insane,  before  he  can  assume  a  position 
of  authority  over  other  attendants,  the  control  of  a  ward, 
and  the  responsibility  of  the  direct  care  of  patients. 

This  last  duty  is  the  most  difficult  of  all,  because  it 
brings  the  attendant  into  intimate  relations  with  a  class 
of  persons,  whose  true  appreciation  of  themselves,  of  their 
conditions  and  surroundings,  is  changed,  whose  thoughts 
and  desires  are  unreasonable,  whose  conduct  is  unnatural, 
and  who  are  largely  controlled  by  insane  delusions,  hal- 
lucinations, and  illusions. 

It  requires  an  intimate  association  with  the  insane,  and 
a  careful  study  of  their  manner  of  thought  and  conduct, 
to  be  able  to  successfully  guide,  direct,  and  control  them. 

22 


THE   DUTIES   OF  AN  ATTENDANT,  23 

The  Relation  of  Attendants  to  Patients. — The  position 
of  attendants  is  often  a  trying  one  ;  they  are  liable  to 
misrepresentation  when  they  have  faithfully  done  their 
duty  ;  they  must  learn  to  receive  with  calmness  a  blow 
or  an  insult,  or  even  so  great  an  indignity  as  being  spit 
upon  ;  they  must  bear  with  provocations  that  come  day 
after  day,  and  are  seemingly  as  malicious  as  they  are 
ingenious  and  designing  ;  they  must  watch  over  the  sui- 
cidal with  tireless  vigilance,  control  the  violent,  and  keep 
the  unclean  clean. 

To  do  all  this  requires  the  exercise  of  self-control  and 
kindness  ;  the  putting  a  curb  upon  the  temper  ;  the  edu- 
cation of  judgment  and  tact ;  faithfulness  in  the  perform- 
ance of  duty,  and  a  knowledge  of  what  to  do  and  what 
to  avoid.  N 

These  trials  are,  however,  but  a  part  of  the  experience 
of  an  attendant  in  caring  for  the  insane,  for  there  is 
associated  in  this  care  much  that  is  satisfactory  and 
pleasurable.  It  is  a  satisfaction  to  know  that  duty  has 
been  well  done  ;  to  be  able  to  care  for  the  sick  ;  to  do 
something  to  alleviate  suffering  ;  to  tenderly  watch  over 
and  soothe  the  dying  ;  it  is  a  pleasure  to  see  a  patient 
improving,  going  on  to  recovery,  and  finally  able  to 
return  home  cured. 

Many  delightful  friendships  are  formed  between  attend- 
ants and  patients,  some  lasting  for  years  within  the 
asylum,  and  some  for  a  lifetime,  with  those  who  have 
recovered.  Most  of  the  insane  appreciate  the  services 
rendered  them,  and  have  a  feeling  of  gratitude  for  those 
who  care  for  them. 

Attendants  should  always  treat  patients  with  politeness 


24  HOW  TO    CARE  FOR  THE  INSANE. 

and  respect ;  it  is  something  that  is  never  thrown  away, 
and  exerts  a  good  influence,  however  rude  and  disrespect- 
ful a  patient  may  behave. 

Patients  should  not  be  ridiculed,  their  mental  weak- 
ness and  peculiarities  made  light  of,  nor  should  they  be 
made  a  show  to  inquisitive  visitors. 

It  is  useless  for  attendants  to  try  to  argue  patients  out 
of  a  belief  in  their  delusions,  and  to  do  so  often  results 
in  fixing  them  more  firmly  in  the  mind.  We  should  not 
however  pretend  to  believe  them,  nor  humor  their  belief, 
nor  allov/  them  to  carry  out  their  delusions  in  their  dress, 
conduct,  and  general  behavior. 

The  Character  of  an  Attendant. — The  insane  should 
always  be  treated  with  kindness,  and  nowhere  is  the 
golden  rule  "thou  shalt  love  thy  neighbor  as  thyself" 
more  necessary  of  application  than  in  caring  for  them  ; 
and  it  is  well  for  attendants,  when  tempted,  to  stop  and 
think  how,  under  like  circumstances,  they  would  want 
their  mother  or  sister  or  brother  treated. 

Keeping  this  noble  teaching  and  this  high  motive  for 
right-doing  ever  in  mind,  an  attendant  cannot  go  far 
astray. 

It  is  a  development  of  character  to  care  for  the  insane, 
and  instead  of  being  brutalizing,  as  some  ignorant 
people  say,  it  is  elevating  and  humanizing. 

Attendants  should  never  gossip,  either  among  or  about 
themselves,  or  of  their  patients.  It  is  a  mean  and' degrad- 
ing habit  to  indulge  in  ;  it  will  undermine  a  good  charac- 
ter, and  often  become  overpowering  and  malicious. 

On  the  other  hand,  never  be  afraid  to  speak  the  truth, 
and  never  let  a  lie,  or  the  semblance  of  a  lie,  pass  your 


THE  DUTIES  OF  AN  ATTENDANT.  25 

lips,  or  remain  for  a  moment  in  your  heart.  Of  all  things 
be  truthful. 

Attendants  must  acquire  a  spirit  of  willing  obedience, 
of  cheerful  execution  of  all  commands  and  directions,  and 
of  faithful  performance  of  every  duty  that  devolves  upon 
themx.  Unless  they  have  this  spirit,  they  will  be  unable 
to  successfully  assume  positions  where  obedience  is  to  be 
exacted  from  others. 

They  should  preserve  their  own  self-respect ;  in  all 
things  set  a  good  example  ;  be  neat  and  tidy  in  their 
dress,  gentlemanly  or  ladylike  in  their  conduct ;  consid- 
erate of  the  wants  and  feelings  of  other  attendants ; 
they  should  "  cherish  a  high  sense  of  moral  obligation  ; 
cultivate  an  humble,  self-denying  spirit ;  seek  to  be  use- 
ful ;  and  maintain  at  all  hazards  their  purity,  truthful- 
ness, economy,  faithfulness,  and  honesty"  (Utica  Asylum 
Rules  and  Regulations). 

In  their  relation  to  the  institution,  attendants  should 
fulfil  all  their  engagements  with  the  same  sense  of  right, 
that  they  expect  will  be  observed  towards  them  by  those 
who  employ  them.  It  is  a  business  contract  that  is  as- 
sumed, and  brings  with  it  mutual  legal  responsibilities, 
rights,  and  obligations.  Attendants  should  strive  to  so 
conduct  themselves,  that  when  they  leave  their  employ- 
ment they  can  go  away  with  the  respect  of  every  one,  and 
bear  with  them  the  reputation  of  a  good  character  and  of 
work  well  done. 

How  and  What  to  Observe  in  the  Care  of  Patients. — It 
is  important  that  attendants  should  early  learn  habits  of 
close  observation.  The  exercise  of  the  habit  increases 
the  ability  to  observe,  and  one  soon  comes  to  see  and 


26  HOW  TO   CARE  FOR  THE  INSANE. 

know  things  he  never  saw,  or  thought  of  before.  It  is 
necessary  to  learn  first  the  physical  condition,  mental 
symptoms,  and  habits  of  a  patient,  before  we  are  able  to 
observe  and  appreciate  any  change. 

Observation,  to  be  of  value,  should  be  systematically 
made,  and  only  one  thing  at  a  time  can  be  noticed,  which 
must  be  understood  before  passing  to  another,  otherwise 
every  thing  is  confused. 

The  condition  and  appearance  of  a  single  part  should 
be  looked  at  to  see  what  is  natural,  and  what  is  evidence 
of  disease. 

In  practice,  written  notes  taken  at  the  time,  are  ex- 
tremely valuable  in  teaching  close  and  accurate  observa- 
tion, and  cultivating  an  ability  to  clearly  express  to  others 
the  result. 

For  the  purpose  of  suggestion  and  guidance,  the  fol- 
lowing system  for  observation  is  given  : 

Observe  the  effect  of  medicine. 

The  face. — Observe  if  it  is  pale,  and  if  the  pallor  is 
sudden,  temporary  or  permanent ;  if  flushed,  if  congested, 
if  blue  with  venous  blood,  if  there  are  any  eruptions, 
bruises,  or  scars.     Observe  the  expression  of  the  face. 

The  tongue. — Observe  if  it  is  coated,  and  if  so,  if  white, 
brown,  red,  black,  glazed,  dry,  or  cracked  ;  if  it  is  tremu- 
lous, or  drawn  to  one  side,  or  protruded  wdth  difficulty. 

The  lips. — Observe  if  pale,  blue,  dry  and  cracked,  if 
there  is  tremulousness  about  the  corners  of  the  mouth  -, 
the  teeth,  if  covered  v/itli  sordes  ;  the  gums,  if  bleeding. 

The  breath. — Observe  if  sv/eet,  sour,  foul,  or  offensive. 

The  respiration. — Observe  if  slow  or  fast,  quiet  and 
natural,  or  loud,  labored,  and  difficult,  if  puffinp^,  wheez- 
ing, shallow,  or  irregular. 


THE  DUTIES   OF  AN  ATTENDANT.  2/ 

The  eyes. — Observe  if  congested,  the  color,  if  any 
blindness  ;  the  pupils,  if  contracted,  dilated,  irregular, 
unequal,  or  if  they  respond  readily  to  light. 

If  there  is  cough,  observe  if  moist  or  dry,  if  croupy,  if 
with  pain,  or  if  prolonged. 

If  any  expectoration,  observe  if  it  is  bloody  or  streaked 
with  blood,  if  thin  and  frothy,  thick  and  purulent,  or  if 
it  sticks  to  the  cup. 

The  pulse. — Observe  if  it  is  slow  or  rapid,  full,  weak 
and  thin,  if  irregular  or  intermitting.     Count  it. 

The  temperature. — Observe  by  the  hand  or  ther- 
mometer. 

The  body.— Observe  for  eruptions  of  the  skin,  for 
sores,  bruises,  or  deformities,  or  if  there  is  any  paralysis. 

The  appetite. — Observe  if  it  is  poor,  changeable,  if 
food  is  relished  or  disliked  ;  if  refused,  if  it  is  constantly 
or  occasionally,  and  if  from  delusions  or  indifference  ; 
if  there  is  overeating  and  gluttony,  if  food  is  bolted,  or 
chewed,  or  if  the  patient  has  teeth  to  eat  with. 

The  digestion. — Observe  if  natural,  or  painful,  and  if 
so,  whether  upon  taking  food,  or  if  the  pain  is  delayed  ; 
if  gas  is  discharged  from  the  mouth,  if  the  stomach  is 
sour,  if  the  food  is  heavy  and  distressing  ;  also  observe 
what  kinds  of  food  give  dyspepsia,  and  what  seem  to  be 
well  borne. 

Of  vomiting. — Observe  if  occasional  or  constant,  if  im- 
mediately after  food,  or  delayed,  if  sour  or  bitter,  if  pre- 
ceded by  pain  or  nausea,  if  it  contains  any  undigested 
food. 

Of  diarrhoea. — Observe  how  frequent  the  discharges, 
if  with  pain,  and  where  it  is   situated,  the  color,  the  con- 


28  HOW  TO   CARE  FOR  THE  INSANE. 

sistency,  if  there  is  any  blood  or  mucus,  if  it  alternates 
with  constipation. 

Of  constipation. — Observe  if  alternating  with  diar- 
rhoea, if  habitual,  the  effect  of  medicine  and  food  ;  if 
there  are  any  piles. 

The  menses. — The  quantity,  if  there  is  any  pain,  its 
cessation  and  reappearance,  if  any  effect  upon  the  mental 
condition. 

Of  pain. — Observe  the  character  and  severity,  its  loca- 
tion, and  any  evidence  of  a  cause. 

Of  dropsy. — Observe  if  it  is  general  or  local,  if  in  the 
chest,  face,  abdomen,  arms,  or  legs  ;  if  there  are  any 
varicose  veins. 

Of  Sleep. — Observe  the  length  of  time,  if  quiet  and 
natural,  if  restless,  if  deep  or  light,  if  there  is  great 
drowsiness  or  continued  wakefulness,  and  the  effects  of 
medicine. 

Of  unconsciousness. — Observe  if  it  comes  on  slowly  or 
suddenly,  if  partial  or  complete,  if  the  patient  can  be 
aroused. 

Of  convulsions. — Observe  if  slight  or  severe,  if  of  short . 
or  long  duration,  if  continued  or  interrupted,  if  general 
or  of  one  side,  or  of  an  arm  or  a  leg,  or  the  face,  or  of  a 
few  muscles  only. 

Of  the  mental  condition. — Observe  if  fixed  or  change- 
able, the  nature  of  delusions,  illusions,  or  hallucinations  ; 
dangerous  attempts  or  threats  toward  himself  or  others  ; 
any  change  in  the  mental  state. 

Of  habits. — Observe  if  fixed  or  changeable,  how  formed 
or  how  corrected. 

Of  the  general  conduct. — Observe  the   dress,  if  neat 


THE  DUTIES  OF  AN  ATTENDANT.  2g 

and  tidy,  or  otherwise,  private  habits,  care  of  personal 
wants,  improvement  in  conduct,  the  influence  of  attend- 
ants and  other  patients,  or  the  influence  the  patient  him- 
self exerts  on  others. 

This  by  no  means  includes  all  that  it  is  necessary  to 
observe,  but  it  contains  much  that  is  important,  and  the 
system,  if  studied  and  used  practically,  will  suggest  to 
the  observer  whatever  may  require  attention. 

T/te  Control  and  Influence  of  Attendants  over  Patients. — 
By  a  "  smart  attendant  "  is  meant  one  who  sees  little  to 
do  beyond  having  a  control  of  the  ward  by  a  rule  that  is 
close  and  exacting,  who  maintains  a  strict  discipline, 
and  who  has  a  love  for  cleanliness,  order,  work,  and 
scrubbing.  But  a  "  useful  attendant "  is  one  who  tempers 
these  mentioned  traits,  by  striving  to  gain  the  confidence 
of  his  patients,  by  exerting  over  them  a  beneficial  influ- 
ence, who  is  able  to  bring  the  individual  patient  into 
accord  with  his  surroundings  in  the  asylum,  so  as  to  help 
his  improvement  or  recovery,  meet  his  wants,  and  increase 
his  comfort  and  enjoyment.  In  order  to  do  this  it  is 
necessary  that  the  attendant  should  give  careful  study 
and  attention  to  each  patient.  Such  a  study  will  soon 
demonstrate  to,  and  teach  the  attendant  the  fact,  that  the 
insane  are  very  individual  in  their  habits,  and  v/hile  no 
two  are  alike,  there  are  resemblances  that  in  an  asylum 
are  made  the  basis  of  classification  by  wards  :  there  is 
the  convalescent,  the  suicidal,  the  demented,  the  sick  and 
feeble,  and  the  noisy  or  violent  wards. 

Attendants  must  first  learn  that  patients  are  not  to  be 
treated  merely  as  a  ward  full  of  people  to  be  kept  in  order, 
to  be  clothed,  fed,  and  put  to  bed,  but  that  the  pecul- 


30  HOW  TO   CARE  FOR  THE  INSANE. 

iarities  of  each  patient  are  to  be  studied,  and  that  it  is 
their  duty  to  know  thoroughly  the  wants,  and  condition 
of  each  case,  and  how  best  to  care  for  and  control  it. 
The  better  knowledge  an  attendant  has  of  the  individual, 
the  better  he  can  care  for  a  ward  full  of  individuals. 

The  persons  who  are  under  our  care  are  always  to  be 
considered  as  patients,  and  it  must  be  remembered  that 
these  sick  people  are  sent  away  from  their  homes  and 
given  over  to  us,  though  strangers,  because  it  is  supposed 
that  we  can  do  better  by  them  than  their  friends  are  able 
to  do. 

Their  position  is  one  of  helplessness  and  dependence 
upon  those  who  are  placed  in  charge,  and  we  are  prop- 
erly held  responsible  by  the  friends  and  the  public,  for  a 
judicious  exercise  of  the  power  and  influence  we  possess 
over  them. 

Patients  are  not  rightly  influenced  by  the  mere  exer- 
cise of  authority  or  by  dictation  or  command  ;  these  they 
fear  and  obey,  or  resent  and  resist  ;  but  we  should 
always  appeal  to  the  highest  motives  for  obedience  and 
correct  conduct,  and  we  should  lead  our  patients  to  trust 
and  not  to  fear  us.  In  our  dealings  with  them  we  should 
be  truthful,  straightforward,  and  strictly  upright,  and  ex- 
ercise over  ourselves  patience  and  self-control. 

We  can  generally  control  our  patients  by  the  exercise 
of  sympathy,  kindness,  and  tact,  joined  with  a  reason  for 
what  is  required,  and  where  more  is  needed,  a  firm,  kind 
authority  and  command  will  suffice. 

The  use  of  authority,  restriction,  and  restraint  is  to  be 
avoided,  while  on  the  other  hand  patients  are  to  be 
allowed  all, the  liberty  and  freedom  they  can  safely  enjoy. 


THE  DUTIES   OF  AN  ATTENDANT.  3 1 

and  taught  to  exercise  all  the  self-control  they  are  capa- 
ble of. 

The  granting  of  more  freedom  and  liberty  of  action 
than  was  formerly  accorded  the  insane,  does  not  imply  a 
change  in  the  character  of  the  disease,  but  improved 
methods  of  care,  and  places  more  responsibility  upon  the 
attendants.  The  degree  of  liberty  to  be  allowed  must,  in 
each  case,  be  decided  by  the  physician,  and  the  attend- 
ants should  closely  observe  the  patient,  and  report  any 
symptoms  which  makes  the  enlarged  freedom  dangerous 
to  the  patient  or  to  others. 

Patients  being  sick,  are  sent  to  the  asylum  that  they 
may  be  kindly  and  judiciously  cared  for,  and,  if  possible, 
cured.  As  many  patients  who  may  never  fully  recover  may 
so  improve  as  to  be  able  to  return  to  their  homes,  and,  as 
it  is  impossible  to  say  that  any  given  patient  will  not 
recover,  each  case  deserves  and  should  receive  our  best 
care  and  efforts  to  this  end. 

Because  our  patients  are  sick  they  must  be  nursed, 
and  nursing  means  tender  care.  And  it  is  a  nurse's  duty 
to  do  all  in  his  power  to  alleviate  pain  and  promote 
bodily  comfort.  The  insane  are  subject  to  all  the  ills 
that  flesh  is  heir  to,  and  there  is  always  among  our  pa- 
tients much  sickness  and  bodily  suffering.  Many  patients 
cannot  tell  when  they  are  sick,  nor  when  they  suffer  pain, 
but  they  show  sickness  and  pain,  and  often  appeal  by 
their  manner  for  that  care  and  sympathy,  we  all  feel  in 
need  of  at  such  times. 

These  silent  symptoms  should  be  observed  by  the  at- 
tendants, who  should  always  see  and  know  when  their  pa- 
tients are   sick.     Some  of  these  symptoms  are,  crying, 


32  HOW  TO    CARE   FOR  THE  INSANE. 

moaning,  weakness,  going  to  bed,  or  lying  down,  cough, 
changes  in  respiration,  signs  of  fever,  a  flushed  face,  quick 
pulse,  or  chills,  a  pale  face,  vomiting,  or  diarrhoea,  and 
loss  of  appetite. 

Much  insanity  is  associated  with  great  physical  dis- 
turbances which  require  careful  nursing.  The  old  and 
feeble,  the  paralytic  and  bedridden  also  require  special 
attention  and  care. 

From  this  it  appears  that  the  care  of  the  insane  calls 
for  the  exercise  of  self-control,  habits  of  close  observa- 
tion, the  using  of  good  judgment,  the  putting  forth  of 
ennobling  influences,  and  the  tender  care  of  the  nurse. 


CHAPTER  V. 

THE    GENERAL    CARE    OF    THE    INSANE. 

" /  "HE  Reception  of  New  Patients. — Attendants  must  at 
once  study  the  peculiarities,  the  physical  condi- 
tion, and  the  mental  symptoms  of  a  new  patient,  so  as 
to  know  the  case  thoroughly. 

New  patients  should  receive  special  attention  ;  their 
fears  quieted  ;  they  should,  if  in  a  proper  condition,  be 
introduced  to  the  other  patients  ;  the  effect  of  being  in 
so  large  and  strange  a  place,  where  the  doors  are  locked 
and  the  windows  guarded  should  be  noticed,  and  un- 
pleasant impressions  overcome  ;  they  must  be  told  they 
have  come  among  friends  and  will  be  kindly  treated. 

The  necessary  rules  of  the  ward  should  be  explained  ; 
they  should  be  invited  to  their  meals,  shown  to  their 
rooms  and  told  at  bedtime  the  night  watch  will  visit 
them,  and  they  must  be  assured  that  no  harm  will  come 
to  them. 

The  first  impressions  a  h^yj  patient  receives  may  be  the 
lasting  ones,  and  influence  their  whole  conduct  in  the 
asylum.  If  they  resist  what  is  necessary  to  do  for  them, 
do  not  struggle  and  contend  with  them,  and  force  them 
to  bed,  or  to  the  bath,  but  first  seek  advice  from  the 
supervisor,  or  the  physician. 

Always  search  new  patients,  unless  otherwise  ordered, 

33 


34  HOW  TO    CARE  FOR  THE  INSANE. 

for  money,  jewelry,  weapons,  medicine,  and  other  like 
articles,  or  if  in  doubt  what  to  do  ask  for  directions. 
The  head,  body,  and  clothing  should  be  examined  for 
vermin,  and  the  body  for  injuries  and  bruises.  If  what 
is  wished  to  be  done  in  this  particular  is  explained,  pa- 
tients will  generally  quietly  allow  it. 

Work,  Ejnployment,  and  Occupation. — By  this  is  meant 
whatever  occupies  the  patient's  time  and  mind,  in  useful 
and  pleasant  ways. 

Of  all  things  idleness  and  loafing  are  the  worst  ;  even 
games,  such  as  billiards  and  cards,  if  indulged  in  to  the 
exclusion  of  useful  employment,  will  degenerate  a  patient. 

Some  willing  patients  are  kept  in  a  tread-mill  of  daily 
work,  their  monotonous  life  never  broken  by  a  diversion, 
an  enjoyment,  or  a  hope.  It  is  very  questionable  if  it 
is  beneficial  to  make  a  patient  drudge  through  such  a 
daily  routine. 

Asylum  life  should  be  made  as  home-like,  pleasant, 
and  natural  as  possible  ;  as  a  rule  every  patient  who  is 
able  should  do  some  useful  work  every  day,  and  to  this 
should  be  added  the  diversion,  that  comes  from  amuse- 
ments and  the  enjoyment  of  innocent  pleasures. 

Occupation  then  means  a  great  deal  more  than  work  ; 
it  is  the  way  a  patient  spends  his  time.  Unless  en- 
couraged and  directed,  patients  may  occupy  themselves 
in  thinking  of  their  delusions,  in  noise,  violence,  or  de- 
structiveness,  in  idly  walking  up  and  down  the  wards,  in 
the  indulgence  of  secret  vices,  in  gossip,  in  spreading  dis- 
content, in  prayer,  or  in  constant  Bible  reading.  Some 
patients  really  work  hard  trying  to  do  nothing,  and  have 
no  more  ambition  than  to  sit  around  on  the  ward,  and 
chew  tobacco,  and  indulge  in  idleness. 


THE  GENERAL    CARE    OF  THE  INSANE.  35 

Patients  should  be  encouraged  to  do  something  for 
themselves,  the  women  to  make  and  mend  their  own 
clothes,  to  keep  their  rooms  in  good  order,  and  assist 
about  the  ward.  They  should  be  made  to  feel  that  they 
can  add  to  their  own  comfortable  surroundings  by  their 
own  efforts. 

For  the  men,  ward  work  is  not  so  natural  or  tasteful, 
but  they  will  do  with  interest  much  of  this  kind  of  work ; 
to  this  may  be  added  employment  in  decorating  their 
own  rooms  or  the  ward,  and  in  caring  for  plants  and 
flowers. 

The  women  can  add  to  ward  work,  sewing,  knitting, 
mending,  embroidery,  artificial  flower  making,  quilting, 
care  of  flowers  in  the  ward,  and  it  is  often  a  real  enjoy- 
ment for  patients  to  make  some  little  present  for  their 
outside  friends.  The  laundry  offers  an  inviting  field  for 
some  patients,  but  it  is  often  too  hard  work,  especially 
when  they  are  sent  twice  a  day  to  the  wash-tub,  or 
kept  in  the  hot  ironing  room.  A  half  day  is  enough  for 
most  patients,  and  many  are  not  strong  enough  to  go 
there. 

Out-of-door  work  is  well  suited  for  the  men.  The 
farm,  garden,  lawn,  barns,  and  machine-shops  offer  much 
that  can  be  made  useful  for  the  patients'  employment ; 
the  different  mechanics  and  artisans  about  the  asylum 
should  have  patients  working  with  them. 

Thus  it  appears  there  are  many  directions  for  patients 
to  work,  and  it  is  also  true  that  all  patients  are  not  suited 
to  do  the  same  work  nor  the  same  amount  of  work. 
Whatever  they  do  should  be  for  their  benefit  alone,  other- 
wise we  might  take  a  contract  for  a  given  number  of 


36  HOW  TO   CARE  FOR  THE  INSANE. 

patients  to  work  a  given  number  of  hours  every  day,  a 
good  deal  as  has  been  done  in  prisons  and  reformatories, 
but  no  one  would  believe  such  a  course  for  the  interest, 
improvement,  or  recovery  of  the  patients. 

The  only  rule  to  go  by  is,  that  the  work  and  occupa- 
tion shall  be  for  their  ov/n  good,  and,  that  they  shall 
not  be  made  or  encouraged  to  work  for  any  other  pur- 
pose. 

As  a  rule,  patients  should  be  allowed  to  employ  them- 
selves in  ways  that  most  interest  them,  provided  it  is 
useful  and  seems  to  be  beneficial. 

Over-work  is  as  bad  as  idleness  ;  too  much  sewing  will 
often  give  a  sleepless  night. 

Generally  all  patients  may  be  allowed  to  engage  in  light 
work,  without  special  directions  ;  new  patients,  however, 
should  not  be  sent  off  the  ward,  or  given  tools  that  may 
become  weapons,  unless  by  order  of  a  physician. 

It  is  a  bad  habit  for  attendants  to  sit  idly  by,  or  stand 
around  with  their  hands  in  their  pockets,  and  have  pa- 
tients do  all  the  work.  It  may  be  so  necessary  to  watch 
the  patients  that  the  attendant  cannot  work  steadily,  but 
he  should  have  the  appearance  of  doing  something,  and 
if  possible  join  with  them  in  work. 

A  party  of  women  sewing,  should  be  laughing,  talking, 
telling  stories,  perhaps  singing  ;  they  should  be  made  to 
enjoy  the  time,  and  not  to  look  upon  it  as  something 
irksome. 

Some  patients  are  too  feeble  in  mind,  and  some  too 
feeble  in  body  to  work  ;  many  need  rest,  quiet,  and  nurs- 
ing, and  directions  for  the  care  and  occupation  of  such 
patients  should  come  from  the  physician. 


THE   GENERAL   CARE   OF  THE  INSANE.  37 

Many  of  these  patients  will  do  a  little,  others  can  be 
amused,  or  read  to,  and  their  minds  thus  diverted  from 
their  troubles,  and  turned  into  pleasant  and  cheerful 
directions  of  thought. 

It  has  been  shown  that  work  is  not  the  only  useful  way 
that  patients  may  occupy  their  time,  that  nothing  but 
work  is  as  bad  as  no  work,  and  that  they  should  have 
diversion,  enjoyment,  and  entertainment. 

For  the  entertainment  and  occupation  of  patients,  there 
are  furnished,  dances,  concerts,  theatricals,  billiards,  cards, 
pianos,  books  and  papers,  schools,  chapel  services,  walks, 
rides,  and  excursions,  and  they  also  receive  visits  from 
friends,  and  write  and  receive  letters. 

Patients  should  be  encouraged  and  sometimes  made  to 
take  part  in  these  natural  and  pleasant  amusements  ;  of 
course  every  patient  cannot  play  the  piano,  or  billiards, 
but  among  these  many  forms  of  recreation,  all  patients 
can  find  ways  of  diversion  and  means  of  enjoyment. 

Thus  early  in  the  study  of  the  care  of  the  insane,  it  is 
learned  that  the  life  of  patients  is  to  be  stripped,  as  much 
as  possible,  .of  restriction  and  restraint ;  that  self-control 
is  to  be  taught ;  that  useful  work  is  to  be  encouraged  ; 
that  amusements  and  innocent  pleasures  are  to  be  en- 
joyed ;  in  a  word,  attendants  are  to  learn,  that  the  char- 
acteristics of  institutional  life  are  to  be  lessened,  and  those 
of  a  home  life  made  prominent. 

The  Patients'  Care  of  Theinselves. — The  general  tend- 
ency of  the  insane  is  to  mental  enfeeblement,  to  neglect 
of  person,  and  to  slovenly  habits.  Patients  should  be  en- 
couraged as  much  as  possible  to  care  for  themselves  ;  to 
be  helpful  towards  others  ;    to  do  such  work  as  they  are 


38  HOW  TO   CARE  FOR  THE  INSANE. 

able  ;  to  seek  amusements,  and  to  live  as  much  as  possi- 
ble such  a  life  as  we  ordinarily  are  accustomed  to  outside 
the  asylum. 

Patients  should  be  encouraged  to  keep  themselves  tidy, 
and  nicely  dressed,  to  have  the  care  of  their  clothing  ;  if 
possible,  they  should  be  given  a  room  of  their  own, 
which  they  should  take  a  pride  in  keeping  in  order,  and 
ornamenting  with  pictures  and  flowers  ;  and  should  be 
allowed  to  do  whatever  will  help  maintain  their  self-re- 
spect, self-care,  and  a  feeling  of  individuality. 

There  is  great  difference  in  patients  as  shown  in  their 
capacity  for  self-help.  Some  seem  to  be  able  to  do 
nothing,  some  everything.  Nothing  can  lighten  the  bur- 
dens of  attendants  so  much  as  to  make  the  helpless  self- 
helpful.  Nothing  benefits  the  patients  more.  Do  not 
abandon  effort  for  any  patient.  Unexpected  and  grati- 
fying results  are  the  rewards  of  earnest  efforts. 

Out  of  Door  Exercise —  Walking. — If  possible,  patients 
should  be  out  of  doors  every  day.  In  the  summer  much 
time  can  be  spent  in  the  fields,  on  the  lawn,  either  walk- 
ing or  sitting  under  the  trees  ;  in  the  winter  time  shorter 
walks  only  can  be  taken,  but  on  pleasant  days,  often  an 
hour  may  be  spent  out  of  doors.  Warm  clothing  and 
good  shoes  must  never  be  neglected,  and  the  person 
must  be  thoroughly  protected,  because  the  insane  are 
frequently  "  cold-blooded,"  that  is,  the  circulation  is 
poor,  the  hands  and  feet  congested,  blue,  and  cold,  they 
make  animal  warmth  slowly  and  with  difficulty,  and  easily 
suffer  from  the  cold. 

Many  patients  go  out  to  walk  on  parole.  Those  who 
are  allowed  this  liberty  will  be  designated  by  the  phy- 


THE    GENERAL    CARE    OF  THE  INSANE.  35 

sicians  ;  any  change  in  the  patient  that  makes  such  liberty 
dangerous  should  at  once  be  reported.  Others  go  out  in 
large  parties,  with  few  attendants  to  care  for  them,  while 
the  old,  sick,  and  feeble,  the  homicidal  and  suicidal,  the 
noisy  and  violent,  require  special  care  and  attention  in 
their  exercise  and  walks. 

Clothing  of  Patients. — In  many  asylums  each  patient 
has  his  own  clothing.  Every  article  should  be  plainly 
marked  with  his  own  name,  and  should  be  used  only  by 
the  patient  to  whom  it  belongs,  and  never  given  to  any 
one  else  to  wear.  All  clothing  should  be  kept  clean  and 
well  mended,  and  should  be  properly  put  on  and  kept  on 
during  the  day.  There  should  always  be  enough  to  keep 
the  patient  warm,  and  changed  with  the  changes  in  the 
weather,  or  the  temperature  of  the  ward,  or  the  needs  of 
the  patient.  The  sick,  feeble,  and  old  always  need  extra 
clothing  ;  that  worn  next  the  skin  should  be  changed  at 
least  once  a  week,  and  all  clothing  should  be  changed  as 
often  as  soiled. 

Bathmg  of  Patients. — Every  patient  should  be  bathed 
once  a  week  and  as  much  oftener  as  is  necessary.  The 
tub  should  be  cleaned  and  the  water  changed  for  each 
patient ;  the  temperature  should  be  about  ninety-five  de- 
grees, or  not  hot  to  the  hand,  and  the  tub  should  be 
about  two-thirds  full.  The  head,  neck,  and  body  should 
be  washed  with  soap  ;  each  patient  should  have  a  clean 
towel,  be  wiped  dry,  and  given  a  change  of  clean  clothing. 

Some  patients  object  to  bathing  ;  they  fear  the  tub,  but 
will  wash  with  water  and  a  sponge,  and  they  should  be 
allowed  to  do  so.  Others  want  to  bathe  first ;  let  them 
if  possible.  Others  will  not  bathe  the  day  the  rest  do  ;  it 
is  sometimes  best  to  humor  them. 


40  BO  IV  TO    CARE  FOR  THE  INSANE. 

Some  patients  have  to  be  forcibly  bathed.  In  such 
cases  always  wait,  use  every  art  to  induce  them  to  bathe, 
and  before  acting  send  for  advice. 

Attendants  are  too  prone  to  think  that  every  thing 
should  be  done  by  rule,  and  that  all  must  be  forced  to 
obey  the  rule.  Most  will  observe  it  without  trouble,  and 
the  object  sought  can  generally  be  gained  by  patience, 
tact,  and  kindness. 

Serving  of  Food. — The  dining-tables  should  be  neatly 
set  and  made  attractive  ;  the  food  should  be  promptly 
served,  and  while  hot ;  all  patients  should  be  at  meals, 
unless  excused  by  the  physicians.  Economy  should  be 
practised,  and  every  thing  should  be  used  or  saved. 
Each  person  should  have  enough,  but  no  one  should  be 
allowed  to  make  a  meal  of  a  delicacy,  or  take  all  of  the 
best  of  a  dish.  Some  patients  would  waste  a  pound  of 
butter  or  sugar  at  each  meal  ;  enough  is  sufficient  for 
anybody. 

The  old  and  feeble  should  be  served  by  attendants  ; 
those  without  teeth  should  have  their  food  prepared, 
and  the  meat  should  be  cut  very  fine.  Those  who  will 
not  eat  must  be  kept  in  the  dining-room  and  fed  ;  the 
attendants  may  use  force  by  holding  the  hands,  and 
placing  food  in  or  to  the  mouth  ;  but  it  is  dangerous  to  do 
more,  and  holding  the  nose  is  something  that  is  never  al- 
lowable. If  these  efforts  to  get  them  to  take  food  do  not 
succeed,  report  to  the  physician.  Some  patients  from 
delusions  will  eat  certain  kinds  of  food,  and  either  not  get 
enough  or  not  a  sufficient  variety. 

A  mixed  diet  is  the  best,  and  patients  should  if  pos- 
sible be  made  to  eat  bread,  butter,  meat,  vegetables,  and 


THE   GENERAL   CARE   OF  THE  INSANE.         4 1 

drink  milk  and  plenty  of  water.  No  patient  should  be 
allowed  to  lose  in  flesh  and  strength  on  account  of  failure 
to  take  sufficient,  or  proper  food  ;  before  these  things 
happen  it  should  be  reported  to  the  physician.  Some 
patients  will  only  eat  enough  if  they  are  allowed  to  eat  it 
in  their  own  way  ;  they  will  eat  it  perhaps  standing,  or 
after  the  others  have  finished,  or  alone,  or  in  their  room, 
or  they  may  steal  it,  if  given  the  opportunity.  Such 
peculiarities  often  have  to  be  indulged. 

Some  patients  will  take  nothing  but  milk,  then  about 
three  quarts  a  day  are  needed  ;  eggs  may  be  added  and 
are  often  readily  taken,  and  some  may  be  got  to  eat  bread 
and  milk,  which  is  a  very  nutritious  diet. 

The  food  of  the  sick  should  be  nicely  and  invitingly 
served,  and  efforts  should  be  made  to  meet  their  whims 
and  fancies. 

Patients  who  are  so  profane,  violent,  or  noisy,  that  they 
are  not  allowed  to  come  to  the  dining-room,  must  always 
be  fed  by,  and  in  the  presence  of  an  attendant,  and  meals 
should  not  be  passed  into  a  patient's  room  and  left  there. 

Knives  and  forks  should  always  be  counted  by  an  at- 
tendant before  and  after  each  meal  ;  care  should  be  used 
that  they  are  not  lost,  secreted,  or  carried  out  of  the 
dining-room  by  patients.  No  one  but  an  attendant  should 
ever  handle  the  carving  knife  and  fork,  or  the  bread  knife. 

Care  of  Patients  when  Going  to  Bed,  or  Rising. — The 
beds  should  be  daily  aired,  and  always  clean  and  nicely 
made  up  ;  for  a  filthy  patient  a  straw  bed,  that  can  be 
changed,  alone  is  clean. 

All  patients  do  not  need  to  go  to  bed  at  the  same  time, 
and  while  some  are  able  to  care  for   themselves,  most 


42  HOW  TO    CARE  FOR  THE   INSANE. 

need  care,  attention,  and  watching.  The  helpless  should 
be  dressed  and  undressed,  and  put  to  bed  first  :  the  vio- 
lent and  homicidal  need  to  be  watched,  and  should  be 
put  to  bed  early,  while  the  suicidal  should  be  kept 
under  supervision,  and  put  to  bed  at  the  most  convenient 
time.  After  a  patient  is  in  bed,  an  attendant  should  go 
into  the  room,  with  a  lantern,  so  as  to  see  that  every  thing 
is  in  order  and  safe,  and,  with  a  cheerful  "  good-night  " 
close  the  door.  Patients  who  need  care  should  be  visited 
during  the  evening,  and  left  clean  and  in  good  condition 
to  be  cared  for  by  the  night  watch. 

In  the  morning  patients  need  attention  before  any  thing 
else  is  done.  First,  the  suicidal,  sick  and  feeble,  the  vio- 
lent, and  those  likely  to  be  filthy  should  be  visited,  and 
every  patient  should  be  washed  and  dressed  before  break- 
fast ;  or,  if  for  any  reason  they  do  not  come  to  this  meal, 
their  faces  and  hands  should  be  washed,  the  bed  put  in 
order,  and  the  room  made  clean  and  aired. 

After  these  things  have  been  attended  to,  the  ward 
work  should  be  done,  though  generally  the  two  can  go  on 
together. 

Care  of  Patients  during  the  Night. — After  the  patients 
have  gone  to  bed  the  ward  should  be  quiet,  doors  should 
be  quietly  closed,  voices  lowered,  and  loud  calls  and 
laughter  not  indulged  in,  squeaking  boots  should  not  be 
worn,  and  heavy  walking  avoided.  Many  patients  go  to 
sleep  early,  but  are  easily  awakened,  and  may  remain 
sleepless  till  morning,  or  at  least  a  part  of  the  night. 

The  night  watchers  have  responsible,  arduous,  and  try- 
ing duties.  Attendants  should  always,  during  the  night, 
quickly  respond  whenever  a  demand  is  made  upon  them 


THE   GENERAL    CARE   OF  THE  INSANE.         43 

for  assistance,  though  an  unnecessary  call  should  never 
be  made.  The  night  watchers  should  be  informed  of  any 
changes  that  have  occurred  during  the  day,  that  will  re- 
quire their  attention  during  the  night  ;  they  should  see 
new  patients  and  be  made  acquainted  with  their  peculiar- 
ities ;  they  should  visit  the  wards  during  the  evening 
before  they  come  to  the  medical  office  to  receive  in- 
structions from  the  physicians. 

It  is  the  duty  of  a  night  watch  to  visit  regularly  all  the 
wards  under  his  charge  ;  to  see  and  know  the  condition  of 
the  sick,  the  helpless,  feeble,  the  suicidal,  and  the  epi- 
leptic ;  to  attend  to,  by  taking  up,  those  who  are  inclined 
to  be  filthy,  and  wash  those  who  need  it,  and  make  them 
their  beds,  and  rooms  perfectly  clean.  He  should  ob- 
serve the  conduct  of  new  patients,  be  watchful  of  the 
violent,  know  how  much  wakeful  patients  sleep,  visit  all 
associated  dormitories,  wait  upon  all  those  who  need  at- 
tention, and  guard  against  fire  and  accident.  The  night 
watch  should  place  each  day  on  the  medical  office  table, 
a  detailed  account  of  every  patient  that  needed  care  or 
attention,  who  was  disturbed,  or  did  not  sleep  during  the 
previous  night. 

Patients  should  be  left  clean  for  the  night  watch,  who 
should  leave  them  in  as  good  condition  in  the  morning, 
for  the  day  attendants,  and  any  neglect  in  these  direc- 
tions should  be  reported  by  either  party.  Sick  patients 
frequently  have  to  receive  special  night  service,  to  be 
watched,  and  given  food  and  medicine.  When  this 
cannot  be  done  by  the  night  watch,  it  devolves  upon  the 
day  attendants,  and  is  a  duty  that  should  be  cheerfully 
rendered. 


44  HOW  TO   CARE  FOR  THE  INSANE. 

During  the  night,  any  accident,  attempt  at  suicide  oi 
to  escape,  or  unusual  violence,  persistent  sleeplessness, 
or  being  out  of  bed,  a  serious  sickness  or  change  for  the 
worse,  or  the  approach  of  death,  should  be  reported  to 
the  physician.  It  is,  in  many  institutions,  the  duty  of 
the  night  watch  to  report  any  neglect  or  misconduct  on 
the  part  of  an  attendant  or  employe,  and  it  is  something 
that  should  be  faithfully  and  impartially  done. 

Having  briefly  sketched  the  general  duties  of  an  attend- 
ant, it  seems  best  to  again  remind  them,  that  an  asylum 
is  built  and  maintained  for  no  other  purpose  than  for 
caring  for  the  insane  ;  that  each  patient  is  entitled  to  the 
best  our  means  can  afford  ;  that  while  the  attendants  are 
not  responsible  for  the  medical  treatment,  they  are  for 
that  kind  and  intelligent  care  it  is  within  their  province 
to  give  ;  and  they  are  also  reminded  that,  so  far  as  it  can 
be  done,  such  personal  attention  is  to  be  given  to  each 
patient  as  will  assist  in  recovery  or  improvement,  or  pro- 
mote his  well-being. 


CHAPTER  VI. 

THE    CARE    OF    THE    VIOLENT    INSANE. 

A  CAREFUL  study  of  each  violent  patient,  of  his 
habits,  delusions,  and  hallucinations,  of  his  peculiar 
manner  of  showing  violence,  and  a  knowledge  of  what  is 
likely  to  provoke  outbursts  is  necessary  to  properly  care 
for  him.  An  attendant's  ability  to  successfully  manage 
a  ward  full  of  patients  will  depend  largely  upon  the 
study  given  to,  and  the  thorough  understanding  of,  each 
case.  Such  study  will  soon  teach  him  that  every  violent 
patient  has  peculiar  and  pretty  constant  ways  of  show- 
ing and  exercising  violence,  and  that  the  same  rule  of 
individuality  holds  good  among  this,  as  it  does  among 
other  classes  of  the  insane. 

Having  learned  what  will  cause  violence,  it  can  often 
be  avoided  by  removing  the  cause  ;  having  learned  the 
symptoms  that  precede  a  patient's  outbursts  of  violence, 
they  can  sometimes  be  averted,  or  preparations  made  to 
control  them  ;  having  learned  in  what  direction  violence 
is  shown,  how  sudden,  blind,  or  furious  it  may  be,  or  how 
slow,  deliberate,  and  planned,  the  attendant  is  better  able 
to  meet,  manage,  and  control  it. 

Few  patients  are  so  continuously  and  furiously  violent 
as  to  need  constant  repression,  and  the  directions  how  to 
care  for  such  patients  can  always  be  given  by  the  physi- 

45 


46  HOW  TO   CARE  FOR  THE  INSANE. 

cian.  Most  violent  patients  are  subject  to  the  firm,  kind 
control  of  attendants,  and  can  be  kept  sufficiently  quiet 
and  orderly  ;  they  should  never  be  left  alone,  and  mops, 
pails,  brooms,  chambers,  and  all  other  articles,  that  may 
become  weapons  should  not  be  left  within  reach.  Strong 
comfortable  clothing  can  generally  be  kept  on  the  most 
violent  and  destructive,  with  care  and  attention  from 
attendants,  but  not  without. 

Many  violent  patients  will  employ  themselves  and  be 
the  quieter  for  so  doing.  Light  out-of-door  work  is  the 
best  employment  for  this  class,  and  out-of-door  walking 
and  exercise  should  never  be  neglected.  On  the  wom- 
an's ward  knitting,  sewing,  mending,  and  ward  work  are 
suitable  for  many,  while  some  will  work  at  the  laundry, 
and  others  will  go  quietly  to  church  and  entertainment ; 
books  and  illustrated  papers  should  be  furnished  and 
will  be  much  read  and  enjoyed. 

As  a  rule  the  more  violent  patients  are  restricted,  kept 
continuously  on  the  ward,  or  in  a  small  room,  and  given 
no  work,  amusements,  walks,  and  exercise,  the  more 
noisy  and  violent  do  they  become. 

Attendants  must  learn  that  mere  noise,  and  much  of 
maniacal  activity,  such  as  running  about,  jumping,  or 
pounding,  is  not  in  itself  harmful,  and  that  unless  such 
patients  are  doing  themselves  injury,  or  so  disturbing  the 
ward  and  other  patients  as  to  require  interference,  it  is 
better  to  control  than  to  repress  and  restrict  them. 

Many  violent  patients  are  subject  to  such  paroxysms 
of  great  violence  as  to  require  immediate  care  and  often 
temporary  control  at  the  hands  of  attendants.  Gen- 
erally these  paroxysms  spend  themselves  after  a  short 


CARE   OF  THE  VIOLENT  INSANE.  47 

time,  but  if  they  do  not,  advice  and  help  can  be  called 
for. 

By  careful  watching,  the  approach  of  these  paroxysms 
can  be  known  and  often  avoided.  This  may  be  done  by 
removing  the  cause,  which  is  often  the  irritation  of 
another  patient  or  an  attendant,  by  a  word,  a  joke,  by 
simply  letting  the  patient  alone,  or  by  a  firm  show  of 
authority,  or  by  any  other  means  experience  has  taught 
to  be  useful  in  the  particular  case. 

If  necessary  to  hold  a  patient,  three  persons  should  be 
able  to  care  for  the  most  violent.  This  can  be  done  by 
grasping  each  arm  at  the  wrist  and  elbow,  and  holding  it 
out  straight,  the  attendants  standing  behind  while  another 
passes  the  arm  about  the  neck  and  holds  the  chin,  to 
prevent  biting  and  spitting  ;  the  patient  may  then  be 
walked  backward  and  seated  in  a  chair 

After  the  violence  has  subsided,  though  the  patient 
should  continue  to  scold,  swear,  threaten,  or  cry,  he 
should,  as  soon  as  possible,  be  left  alone,  the  attendants 
walking  away,  but  remaining  watchful.  Do  not,  unless  it 
is  necessary,  interfere  to  stop  the  noise,  for  it  is  often  a 
substitute  for  the  violence,  and  the  attack  wears  itself  out 
in  this  way. 

If  necessary  to  carry  a  violent  patient,  it  can  be  done 
by  four  or  six  attendants.  The  face  should  be  turned 
downward,  thereby  lessening  the  power  to  resist,  and,  to 
prevent  dislocating  the  arms,  the  patient  should  be 
carried  by  the  shoulders  and  chest ;  the  bands  about 
the  neck  should  be  loosened. 

In  using  force  in  the  care  of  violent  patients,  it  should 
always  be   done   as  gently    as    possible,   and    struggling 


48  HOW   TO   CARE  FOR    THE  INSANE. 

should  be  avoided  ;  he  should  never  be  choked  or  kicked, 
receive  a  blow,  or  be  knocked  dov/n  ;  the  arms  should 
never  be  twisted,  nor  a  towel  held  over  the  mouth,  but  if 
the  patient  persists  in  spitting  it  may  be  held  in  front  of 
the  face. 

Care  must  always  be  used  not  to  injure  a  patient  while 
exercising  necessary  control.  In  the  violence  of  a  patient 
innocent  injuries  are  sometimes  received.  The  attendant 
is  excusable  if  he  can  show  that  he  used  necessary  force 
only,  without  malice. 

A  violent  patient  should  never  be  struggled  with 
alone,  and  on  a  well-managed  ward  help  will  always  be 
within  call.  It  may  be  necessary,  however,  to  break  this 
rule  in  order  to  prevent  homicide  or  suicide,  or  serious 
injury  to  another  patient,  or  setting  the  house  on  fire. 

It  is  better  not  to  visit  the  room  of  a  violent  patient 
alone,  and  if  an  attack  is  feared,  especially  with  a  weapon, 
the  door  should  be  slowly  opened,  and  held  so  it  can  be 
quickly  closed.  The  patient  usually  makes  an  immedi- 
ate attack,  and,  before  he  has  recovered  for  a  second, 
can  generally  be  disarmed  and  controlled. 

Violence  usually  consists  of  noise,  tearing  the  cloth- 
ing, breaking  glass  or  furniture,  biting,  scratching,  strik- 
ing, hair  pulling,  kicking,  or  attacking  others  with 
weapons.  It  is  sometimes  secretly  and  deliberately 
planned  and  skilfully  executed,  though  generally  without 
reasoning  or  direction,  but  blind  and  fierce. 

The  care  of  the  violent  insane  involves  the  careful 
study  of  each  case,  with  constant  watchfulness,  and  the 
exercise  of  a  control  that  is  kind,  but  firm  and  unyield- 
ing, that  does  not  repress  except  when  necessary,  nor 
restrict  without  reason,  that  indulges  whenever  possible, 


CARE   OF  THE  VIOLENT  INSANE.  49 

that  never  drives,  scolds,  or  threatens,  but  influences, 
guides,  and  directs.  The  greatest  liberty  possible  should 
be  allowed,  and  self-control  encouraged,  and  work,  occu- 
pation, and  amusement  should  be  furnished.  An  attend- 
ant must  always  remember  that  fear  is  the  lowest  motive 
to  govern  by,  and  that  kindness  will  often  be  appreciated 
and  returned. 

Care  of  the  Destructive  'Patients. — Besides  the  violently 
destructive  patients,  there  are  some  who  are  maliciously 
destructive,  and  who  exercise  all  their  ingenuity  to  escape 
the  watchfulness  of  the  attendants  ;  who  glory  in  their 
wrong-doing  ;  who  openly  say  they  cannot  be  punished, 
and  exultantly  tell  the  physician  how  they  have  out- 
witted the  attendant,  or  proclaim  before  him  his  short- 
comings and  neglect.  Such  patients  will  destroy  their 
own  or  others  clothing,  they  will  steal  and  hide,  or  throw 
it  out  the  window  or  down  the  water-closet,  or  erase 
the  name  by  which  it  is  marked.  They  will  destroy  bed- 
ding, windows,  crockery,  pictures,  or  furniture.  With  a 
pin,  a  nail,  or  a  bit  of  glass  or  wood,  they  will  mar  and  de- 
face their  room  or  the  ward,  and  often  do  damage  that 
■cannot  be  repaired.  The  only  way  to  meet  such  cases  is 
by  watchfulness.  They  should  be  kept,  if  possible,  at 
work,  or  at  least  with  a  company  of  workers,  and  there- 
fore under  constant  observation.  When  put  to  bed  their 
clothing,  mouth,  hair,  and  person  should  be  thoroughly 
searched.  Kindness  often  has  but  little  effect,  but  a 
threat  is  apt  to  make  them  more  determined  to  destroy. 

The  Care  of  Patients  by  Mechanical  Restraint  atid  Seclu- 
sion.— All  the  restriction  of  an  asylum  is  restraint.  The 
locking  of  bedroom  doors  at  night  is  very  restricted  re- 


50  HOW  TO   CARE  FOR  THE  INSANE. 

straint.  Most  patients  in  an  asylum  have  a  feeling  that  they 
are  under  great  compulsion  and  restraint,  in  being  deprived 
of  their  liberty.  It  has  already  been  taught  that  patients 
are  to  be  given  all  the  liberty  possible,  that  restraint  over 
their  freedom  is  to  be  exercised  no  more  than  is  abso- 
lutely necessary,  and  that  the  greatest  good  of  the 
patients  alone  is  to  be  thought  of. 

These  teachings  are  equally  true  of  special  forms  of 
restraint.  If  used  at  all  they  are  to  be  used  for  the  good 
of  the  patient  alone,  and  an  attendant  should  be  able  to 
care  for  any  case  without  restraint. 

Restraining  apparatus  should  never  be  kept  on  the 
ward.  An  attendant  should  never  ask  that  it  be  used, 
nor  say  he  cannot  get  along  without  it. 

If  ordered  by  the  physician  it  is  the  attendant's  duty 
to  see  that  it  is  so  applied  as  to  do  no  injury,  that  it  does 
not  bind  or  tie  the  patient  down,  that  it  does  not  irritate 
and  make  the  skin  sore,  nor  restrict  the  free  movement 
of  the  limbs. 

Patients  who  are  restrained  are  not  to  be  further 
confined  to  a  chair  without  specific  order.  Restraint 
used  during  the  day  is  not,  unless  so  ordered,  to 
be  continued  at  night  nor  reapplied  the  next  day.  Pa- 
tients are  to  be  taken  frequently  to  the  closet.  Restraint 
should  be  taken  off  several  times  a  day,  and  kept  off  long 
enough  to  give  relief  to  any  feeling  of  discomfort,  and 
free  movement  should  be  allowed.  When  patients  are 
restrained  they  need  unusual  care  and  watching,  and 
should  never  be  left  alone. 

The  attendant  should  be  informed  why  restraint  is 
used,  and  what  is  hoped   to  be  gained  by  its  use.       He 


CARE   OF  THE  VIOLENT  INSANE.  51 

should  closely  observe  the  effect  upon  the  patient  and 
compare  his  condition  with  what  it  is  when  not  re- 
strained. The  result  of  these  observations  should  be 
reported. 

Thus  used,  an  attendant  will  soon  learn  that  it  is  not 
the  easiest  way  to  care  for  a  patient,  that  its  use  involves 
increased  watchfulness  and  care,  and  greater  discretion, 
and  that  it  is  strictly  a  form  of  medical  treatment.  It  is 
a  harsh  remedy  at  its  best,  and  needs  to  be  used  with 
kindness,  intelligence,  and  judgment,  and  it  is  to  be  ap- 
plied but  for  one  purpose,  namely,  that  the  patient  may 
be  benefited. 

The  Use  of  the  Covered  Bed. — Like  restraint  it  is  never 
to  be  used  except  by  the  orders  of  a  physician,  nor  is  its 
use  to  be  repeated  without  special  orders  ;  it  is  always  to 
be  considered  a  method  of  treatment  and  something  the 
attendant  has  no  interest  in,  except  to  know  how  best  to 
use  it  when  ordered  to  do  so. 

When  in  a  covered  bed  the  patient  should  be  frequently 
visited  ;  he  should  be  taken  up  at  least  once  in  three 
hours,  unless  asleep  ;  the  bed  and  the  patient  should  be 
kept  perfectly  clean.  If  used  in  the  daytime  an  attend- 
ant should  sit  beside  the  patient  for  some  hours  and  try 
to  keep  him  quietly  in  bed,  and  the  same  should  be  done 
in  the  evening  when  the  patient  is  put  to  bed.  An 
attendant  should  be  able  to  report  how  much  the  patient 
sleeps,  how  much  quiet  and  rest  is  obtained,  the  effect  of 
the  treatment,  and  compare  the  condition  of  the  patient 
when  in  the  bed  with  what  it  is  when  not  used. 

The  Use  of  Seclusio?i. — Seclusion  is  shutting  a  patient 
alone  in  a  room  in  the  daytime.       If  allowed  to  be  done 


52  HOW  TO   CARE  FOR  THE  INSANE. 

without  orders  from  the  physician  it  should  be  im- 
mediately reported.  If  ordered  to  be  continued  the  pa- 
tient should  be  seen  at  least  once  in  fifteen  minutes, 
while  many  need  to  be  seen  once  in  five  minutes,  and  an 
attendant  should  never  be  far  from  the  door.  The  pa- 
tient should  be  frequently  taken  to  the  closet.  The  effect 
and  result  of  seclusion  should  be  observed  and  re- 
ported. 

Many  physicians  never  use  any  form  of  restraint,  while 
others  make  considerable  use  of  it  as  a  means  of  treat- 
ment. An  attendant  should  be  able  to  successfully  care 
for  any  case,  so  as  to  meet  the  wishes  and  directions  of 
the  physician,  and  only  as  he  is  able  to  do  this  can  he 
give  the  patient  the  highest  standard  of  attention,  care, 
and  nursing. 


CHAPTER  VII. 

t 

THE     CARE     OF     THE     HOMICIDAL,    SUICIDAL,     AND    THOSE 
INCLINED    TO    ACTS     OF    VIOLENCE. 

pATIENTS  with  Delusions  of  Suspicion  demand 
special  care,  and  are  properly  classed  with  those 
inclined  to  commit  acts  of  violence,  because  they  are 
frequently  fully  under  the  control  of  delusions,  which 
make  them  dangerous  and  difficult  to  manage. 

Many  patients  have  ideas  that  make  them  suspicious 
of  those  about  them  ;  these  may  relate  to  the  patients, 
but  more  frequently  to  the  attendants  and  physicians, 
and  they  may  arise  from  delusions,  hallucinations  or 
illusions.  This  class  of  patients  is  apt  to  be  morose, 
cross,  and  irritable  ;  they  sit  brooding  over  their  fancied 
wrongs  ;  repulse  advances  and  friendly  intercourse  ;  they 
refuse  to  employ  themselves,  and  do  not  respond  will- 
ingly to  the  requirements  of  the  attendants. 

Our  most  trifling  and  unmeaning  acts  may  give  rise  to 
the  most  intense  suspicions  and  hatred.  A  look,  a  shrug 
of  the  shoulder,  the  manner  of  shaking  the  head,  a  cough, 
the  squeaking  of  our  boots,  are  frequently  enough  to 
arouse. these  feelings. 

Suspicious  patients  often  think  they  are  the  subjects 
of  ridicule  ;  that  their  thoughts  are  read  and  proclaimed 
to  the  ward  ;  that  their  virtue,  truth,  or  honor  is  called 

53 


54  ^OW  TO    CARE  FOR  THE  INSANE. 

in  question,  and  the  accusations  openly  told  to  others, 
or  that  they  are  called  vile  and  insulting  names.  They 
often  have  delusions  of  conspiracy  to  do  them  or  their 
families  harm,  and  connect  the  attendants  and  physicians 
with  them,  thinking,  as  they  keep  them  locked  in  the 
asylum,  they  are  associated  in  the  conspiracy.  Some- 
times these  patients  think  themselves  some  great  persons, 
perhaps  that  they  are  a  member  of  the  Deity,  or  a  ruler, 
or  prophet,  or  that  they  have  some  great  mission  to  per- 
form, and  that  they  are  deprived  of  their  rights,  or  their 
work  interfered  with,  by  bemg  kept  in  the  asylum,  and 
that  those  in  authority  are  imprisoning  and  persecuting 
them.  Such  persons  may  be,  on  account  of  their  fancied 
wrongs,  very  suspicious,  and  even  violent  towards  those 
who  care  for  them. 

Other  patients  have  suspicions  and  fears  of  bodily 
harm.  They  may  think  they  are  to  be  tortured,  that 
they  are  to  be  burned  alive,  or  that  some  one  is 
trying  to  kill  them.  To-day,  as  I  wrote  these  lines, 
a  patient  told  me  she  did  not  sleep  last  night  for 
fear  the  night-watch  would  kill  her — saying  that  God 
told  her  the  watch  was  armed  Avith  a  knife  for  that  pur- 
pose, and  she  threatened  homicidal  violence  in  defending 
herself. 

Many  patients  mistake  ordinary  sensations  of  pain  and 
bodily  discomfort,  and  have  delusions  that  they  are  being 
injured.  The  feelings  of  dyspepsia  may  make  patients 
think  they  have  been  poisoned  ;  ordinary  pains  or  aches, 
that  they  have  been  shot,  stabbed,  or  pounded  ;  women 
may,  for  some  such  causes,  think  they  have  been  violated 
or  are  pregnant.     Peculiar  sensations  of  various  kinds 


CARE    OF  THE  HOMICIDAL,  ETC.  55 

may  make  patients  think  some  one  is  affecting  them  by 
electricity  or  mesmerizing  them. 

It  is  very  easy  to  trace  from  such  ideas  of  persecution 
and  suspicion,  the  origin  of  homicidal,  suicidal,  incen- 
diary and  other  violent  tendencies  and  acts. 

Homicidal  Patients. — Patients  are  sometimes  both  homi- 
cidal and  suicidal,  and  sometimes  they  are  inclined  to 
only  one  of  these  forms  of  violence.  Homicides  are  not 
of  frequent  occurrence  in  an  asylum.  The  better  the 
care  the  less  is  the  liability  to  homicide.  But  there  are 
always  a  great  many  homicidal  patients,  and  many  more 
who  have  delusions  and  ideas  that  may  cause  such  ten- 
dencies to  arise. 

Many  patients  are  homicidal  merely  from  violence  and 
frenzy,  and  without  any  settled  plan,  any  fixed  delusion, 
or  intense  suspicion.  They  may  attack  others  suddenly 
and  furiously  ;  they  may  commit  the  act  while  trying  to 
escape,  or  it  may  be  the  result  of  the  violence  of  acute 
mania.  Other  patients  become  homicidal  under  the  de- 
sire to  protect  themselves  from  supposed  assaults.  They 
may  think  a  person  who  is  approaching  them  is  coming 
to  kill  or  torture  them.  Others  are  homicidal  from  any 
of  the  ideas  of  persecution  and  suspicion  that  have  just 
been  spoken  of.  Sometimes  patients  hear  voices  telling 
them  to  commit  the  act,  perhaps  it  is  God's  voice  com- 
manding a  father  to  offer  up  his  only  son  as  a  sacrifice, 
or  a  mother  to  kill  her  little  children  to  save  their  souls, 
or  keep  them  from  some  misery  or  crime  that  awaits 
them.  Patients  may  think  themselves  God,  or  a  king,  or 
ruler,  and  therefore  have  a  right  to  take  life.  Homicidal 
patients  are  often  among  the  quietest,  and  are  found  in 


56  HOW  TO   CARE  FOR  THE  INSANE. 

the  quiet  wards.  They  frequently  lay  careful  plans,  are 
secretive,  and  only  try  to  commit  the  act  when  they  feel 
sure  it  will  succeed. 

Patients  who  are  homicidal  should  be  especially  watched. 
They  should,  if  possible,  be  kept  employed,  but  never 
given  tools  that  may  become  weapons.  They  should 
sleep  in  a  room  by  themselves.  All  persons  against  whom 
they  have  delusions  should  be  warned.  Patients  against 
whom  they  harbor  suspicious  or  homicidal  ideas  should 
be  separated  from  them. 

Attendants  should  remember  that  a  mop,  a  pail,  or  a 
chair,  may  become  a  dangerous  weapon,  or  that  a  knife, 
scissors,  or  a  sharpened  piece  of  iron  or  tin,  may  make  a 
fatal  wound. 

Suicidal  Patients. — Patients  with  this  tendency  will 
generally  talk  freely  of  their  suicidal  ideas,  tell  why  they 
wish  to  commit  it,  what  provokes  the  idea,  and  how  they 
would  do  the  act.  They  are  frequently  grateful  for 
the  care  bestowed  to  help  them  resist  the  impulse, 
and  will  sometimes  tell  the  attendants  when  they  feel  the 
suicidal  ideas  coming  on,  that  they  may  be  the  more 
surely  watched. 

Melancholic  patients  are  most  inclined  to  suicide,  but 
any  insane  person,  whatever  the  mental  state,  may  com- 
mit the  act.  Delusions  of  depression  generally  cause  the 
suicidal  ideas,  but  hallucinations  sometimes  play  an  im- 
portant part.  Some  persons  are  simply  tired  of  life,  and 
see  no  hope  in  living  ;  some  think  they  are  a  burden  to 
their  friends,  and  that  they  are  taking  food  away  from 
their  children  ;  others  wish  to  die  to  escape  from  their 
misery,   which   is  generally  a  mental,  and  not  a  physical 


CARE    OF  THE  HOMICIDAL,  ETC.  57 

suffering  ;  others  that  by  so  doing  they  may  get  forgive- 
ness of  their  sins  ;  others  because  they  think  they  will 
save  their  children  from  a  fate  like  theirs  ;  sometimes 
it  is  the  result  of  hallucination,  as  a  direct  command  from 
God,  telling  them  to  commit  the  act. 

But  few  patients  are  constantly  determined  to  commit 
suicide.  The  opportunity  offered,  as  a  bath-room  door 
left  open,  a  rope,  a  knife,  often  prompts  the  desire  and 
allows  the  accomplishment  of  the  deed. 

Attendants  must  remember  that  it  takes  but  a  few  min- 
utes to  commit  suicide,  by  drowning  or  hanging — but  a 
moment  to  cut  the  throat ;  that  persons  can  drown  them- 
selves in  a  pail  of  water,  hang  themselves  by  the  hem  of 
the  sheets,  cut  their  throat  with  a  piece  of  glass  or  tin. 
Sometimes  patients  slyly  save  their  medicine  until  they 
get  enough  to  poison  themselves. 

About  dusk  in  the  evening,  or  at  early  morning,  is  the 
time  when  patients  are  most  inclined  to  commit  suicide. 
When  patients  are  rising,  going  to  bed,  or  to  their  meals, 
when  going  to  chapel,  amusements,  or  to  walk,  when  all 
is  busy  and  astir  on  the  ward,  are  the  times  that  offer  the 
most  favorable  opportunities  for  the  act. 

Often  patients  have  a  certain  way  by  which  they  wil\ 
commit  suicide,  and  they  will  do  it  in  no  other  ;  one 
wishes  to  drown  himself,  another  to  hang,  and  another  to 
take  poison.  Sometimes  patients  will  appear  cheerful  to 
avoid  suspicion  and  so  find  their  opportunity,  while 
others  may  suddenly  and  while  convalescent  commit 
the  act. 

The  only  way  to  care  for  patients  who  are  suicidal,  is  by 
constant  watchfulness  day  and  night.     During  the  day 


58  HOW  TO    CARE  FOR  THE  INSANE. 

they  should  be  employed  and  kept  with  other  patients, 
they  should  be  especially  looked  after  at  those  times 
when  opportunities  for  suicide  are  increased.  At  night 
it  is  better  to  have  them  sleep  in  an  associated  dormitory 
with  some  one  to  watch  them.  If  a  patient  is  found  hang- 
ing he  should  at  oDce  be  cut  down,  all  restriction  about  the 
neck  removed  and  artificial  respiration  set  up,  or  if 
drowning,  the  mouth  and  lungs  should  be  first  emptied 
of  water  ;  if  there  is  hemorrhage  compression  should  be 
made  upon  the  artery,  or  if  this  is  not  possible,  then 
directly  upon  the  wound.  How  to  control  hemorrhage 
and  do  artificial  respiration  will  be  described  in  the  chap- 
ter on  emergencies. 

Patients  Who  Have  Tendencies  to  Self -Mutilation. — 
Some  patients  horribly  mutilate  themselves.  They  may 
gouge  out  an  eye,  cut  off  a  hand,  pull  out  their  tongue, 
or  even  disembowel  or  dreadfully  burn  themselves.  Some 
patients  persistently  beat  their  heads  against  the  wall  or 
floor,  others  scratch  the  skin,  making  large  sores.  Such 
patients  frequently  think  certain  passages  from  the  Scrip- 
tures apply  to  them,  and  they  must  obey  the  application 
and  command.  They  quote  in  justification  of  the  acts, 
"  An  eye  for  an  eye,"  "  And  if  thy  right  eye  offend  thee, 
pluck  it  out,"  ''  And  if  thy  right  hand  offend  thee,  cut  it 
off."  Talk  of  this  kind  should  make  an  attendant  very 
careful  and  watchful  of  the  patient. 

The  origin  of  the  ideas  that  lead  to  the  attempts  at 
self-mutilation  is  to  be  found  in  delusions,  and  arise  in 
the  same  way  as  do  ideas  of  suicide  and  homicide. 
These  patients  are  all  of  the  same  class  and  need  the 
same  character  of  care,  attention,  and  watching. 


CARE    OF  THE  HOMICIDAL,  ETC.  59 

Patients  with  Tendencies  to  Setting  Things  on  Fire. — 
Patients  with  these  tendencies  generally  desire  to  com- 
mit incendiary  acts  under  the  influence  of  delusions  or 
hallucinations  ;  added  to  these  there  are  frequently  sus- 
picions and  feelings  of  wrong  treatment,  and  the  patient 
takes  this  way  of  showing  revenge,  or,  as  he  may  say,  of 
repaying  the  wrong.  Sometimes  patients  are  so  feeble  in 
mind  that  they  light  a  fire  because  they  think  it  is  a 
pretty  sight  to  see  it  burn.  There  are  some  conditions 
accompanying  epilepsy  where  patients  are  liable  to  com- 
mit any  of  the  class  of  violent  acts  described  in  this 
chapter.  The  special  care  demanded  by  these  patients 
will  be  fully  spoken  of  hereafter. 

There  are  some  patients  vrhose  minds  are  so  distorted 
by  disease  that  they  seem  to  take  a  pleasure  in  wrong- 
doing, and  are  much  inclined  to  do  great  mischief,  and 
sometimes  to  commit  acts  against  life  or  property. 

The  care  demanded  by  patients  who  are  inclined  to 
acts  of  violence  is  practically  the  same  for  all.  The  at- 
tendant should  thoroughly  know  the  habits,  peculiarities, 
and  delusions  of  each  person  under  his  care ;  he  should 
exercise  constant  watchfulness,  and  rememiber  that  a 
moment  of  thoughtless  inattention  may  give  the  oppor- 
tunity for  a  patient  to  commit  some  violent  act,  that  will 
cause  him  lasting  regret.  The  mind  of  a  faithful  attend- 
ant will,  when  upon  duty,  always  be  full  of  anxiety,  and 
there  should  be  in  the  care  of  very  troublesome  patients 
of  this  class  frequent  relief. 


CHAPTER  VIII. 

THE    CARE    OF    SOME    COMMON    MENTAL    STATES,  AND 
ACCOMPANYING    BODILY    DISORDERS. 

/^^ARE  of  Patients  in  the  Earlier  Stages  of  Insanity. — 
Patients  in  the  earlier  stages  of  insanity  act  differ- 
ently, one  from  the  other,  when  first  brought  to  the  asylum 
and  placed  under  care  and  restriction.  Sometimes  patients 
accept  the  situation  and  fit  into  asylum  life  without  any 
friction.  They  may  even  come  willingly,  knowing  they 
need  care  and  treatment,  or  from  confidence  in  their 
friends  or  their  physician's  advice. 

To  some  patients  the  restrictions  of  an  asylum  are 
irksome  and  misunderstood  ;  the  quiet,  regularity,  and 
routine  of  the  life  on  the  ward  does  not  at  first  affect 
them  ;  they  may,  and  often  do,  become  fretful,  are  irri- 
tated by  their  confinement,  sleep  poorly,  eat  little,  and 
may  make  violent  efforts  to  escape. 

These  conditions,  if  nothing  is  done  to  occupy  the  pa- 
tient's time  and  mind,  and  so  relieve  them,  will  often  be 
sufficient  to  provoke  violence.  These  patients  should  be 
carefully  watched  and  their  condition  studied  ;  they 
should  be  brought  under  the  kind  control  and  influence 
of  attendants,  induced  to  take  part  in  the  regular  order 
of  the  ward,  and,  if  strong  enough,  should  be  furnished 
with  proper  work  and  occupation. 

60 


SOME    COMMON  MENTAL   STATES.  6 1 

Patients,  when  first  brought  to  the  asylum,  frequently 
have  much  anxiety  about  their  homes,  their  families,  or 
their  business  affairs.  This  is  particularly  true  in  recent 
cases  of  insanity,  because  such  patients  often  have  cares 
and  responsibilities,  or  they  have  tried  to  continue  to 
assume  them,  up  to  the  time  of  coming  to  the  asylum. 
Special  care  should  be  taken  to  quiet  fears  in  these  direc- 
tions ;  they  should  be  assured  that  they  are  groundless, 
told  they  will  be  allowed  to  communicate  with  their 
friends,  that  they  will  be  visited  by  their  family,  and  that 
all  their  interests  will  be  cared  for. 

It  is  impossible  to  speak  of  the  varied  causes  of  insan- 
ity, or  of  the  equally  varied  manifestations  of  the  disease 
and  conduct  of  the  patient  at  its  onset,  but  there  are  a 
few  conditions  which,  being  present,  give  a  character  to 
a  particular  case,  and  suggest  the  care  required. 

Sometimes,  as  has  been  said,  the  patient  partly  realizes 
his  condition,  and  is  willing  to  come  to  the  asylum,  and 
in  every  way  to  conduct  himself  in  accordance  with  the 
rules  and  requirements. 

Sometimes  the  onset  is  slow  and  the  symptoms  so  ob- 
scure as  to  attract  little  atttention.  Following  this,  more 
decided  symptoms  may  appear  ;  the  patient  may  become 
violent,  noisy,  destructive,  or  sleepless,  or  he  may  try  to 
commit  suicide  or  homicide,  or  do  some  other  act  of  vio- 
lence ;  or  the  great  restlessness,  moaning,  crying,  and 
sleeplessness  of  melancholia  may  come  on,  or  the  patient 
may  refuse,  for  several  days,  all  food.  The  reason  for 
bringing  such  patients  to  the  asylum  is  that  they  can  no 
longer  be  kept  at  home. 

Following  the  treatment  that  has  been  described,  these 


62  IIOW  TO    CARE  FOR  THE  INSANE. 

patients  will  frequently  in  a  short  time  become  more 
quiet,  self-controlled,  and  more  easily  influenced  and 
cared  for. 

The  earlier  stages  of  insanity  are  frequently  accom- 
panied by  considerable  disturbance  of  bodily  health.  The 
appetite  is  poor,  the  digestion  disordered,  the  bowels 
constipated,  the  breath  foul,  the  secretions  of  the  skin 
changed  and  often  offensive,  the  temperature  a  little 
elevated,  the  pulse  rapid,  and  the  heart  weak.  Some- 
times, on  the  other  hand,  the  temperature  is  normal,  or 
a  little  below,  while  the  hands  are  cold  and  clammy.  In 
addition,  nutrition  is  frequently  impaired,  so  that  the 
food  taken  by  patients  does  not  seem  to  properly  nourish 
and  strengthen.  All  of  these  symptoms  are  not  present 
in  a  given  case  ;  sometimes  most  of  them  may  be,  and 
again  but  few  are  to  be  noticed. 

The  important  lesson  to  learn  in  the  care  of  these 
cases  is  that  such  patients  may  rapidly  pass  into  a  more 
serious  condition,  in  which  there  is  great  exhaustion, 
which  is  always  alarming,  and  may  even  result  fatally. 

Recent  cases,  such  as  have  been  spoken  of,  need  our 
best  care,  closest  attention,  and  kindest  nursing.  The 
patient  should  daily  take  sufficient  food,  which,  if  neces- 
sary, should  be  enforced,  and  the  opportunity  for  sleep 
promoted.  A  few  days,  or  a  day,  without  food  and  sleep 
may  bring  on  alarming  symptoms. 

For  these  patients,  milk  is  the  best  article  of  diet  ;  it 
is  most  easily  given  and  readily  taken  ;  it  should  be 
given  by  the  glassful,  or  if  not  able  to  do  this  by  the 
spoonful.  Some  patients,  for  reasons  not  always  known, 
will  refuse  food  one  hour  and  take  it  freely  the  next ;  it 


SOME    COMMON  MENTAL    STATES.  63 

should,  therefore,  be  frequently  offered.  With  milk  as. a 
basis,  v/e  may  add  to  it,  as  wc  are  able.  Raw  egg,  gruel, 
boiled  rice,  oatmeal,  custard,  and  bread  are  adjuncts  that 
are  nutritious  and  easily  given. 

It  makes  but  little  difference  why  patients  refuse  food, 
except  that  a  knowledge  of  the  reasons  may  enable  us  to 
overcome  their  disinclinations.  The  thing  to  remember 
is  that  they  must  in  some  way  be  made  to  get  enough. 

Care  of  Patients  with  Insanity^  Accompaiiied  by  Exhaus- 
tion.— There  is  a  condition  associated  with  acute  mania 
or  melancholia — though  it  is  sometimes  seen  in  connec- 
tion with  the  more  chronic  forms  of  insanity, — of  exhaus- 
tion so  overpowering,  that  it  may  be  rightly  compared 
with  the  exhaustion  of  typhoid  fever.  It  may  last  a  few 
days  or  a  month,  or  more,  if  it  does  not  sooner  terminate 
fatally.  Instead  of  the  quiet  delirium  of  typhoid  fever 
there  is  generally  violent  mania  or  frenzy.  Neither  mind 
nor  body  is  quiet ;  sleep  seems  to  have  fled.  The  patient 
may  be  destructive,  constantly  out  of  bed,  fighting  care, 
refusing  food,  and  wetting  and  dirtying  himself.  With 
these  unfortunate  conditions  there  generally  is  fever, 
often  to  a  considerable  degree,  the  heart  is  feeble,  the 
pulse  rapid,  the  tongue  and  lips  dry  and  cracked,  the 
teeth  covered  with  sordes,  and  the  body  emaciated. 
Every  case  does  not  present  all  these  symptoms,  nor 
show  such  alarming  exhaustion.  There  are  many  degrees 
of  severity  in  this  sickness. 

Such  patients  must  never  be  left  alone  and  need  con- 
stant nursing  day  and  night.  They  must  have  food,  even 
if  it  is  given  forcibly.  They  must,  if  possible,  be  kept  in 
bed,  and  covered  with  clothing,  and  they  must  be  kept 


64  BOW  TO   CARE  FOR  THE  INSANE. 

clean.  If  wakeful,  food  must  be  administered  during  the 
night,  and  especially  towards  morning,  which  is  the  time 
of  greatest  weakness  and  physical  depression. 

Hot  baths  maybe  ordered  for  these  patients,  and  stim- 
ulants and  medicine  to  produce  sleep  left  in  the  care  of 
attendants.  How  to  give  the  baths  and  medicine,  what 
results  are  to  be  expected,  and  what  dangers  are  to  be 
feared,  will  be  described  later,  in  the  chapter  on  the  ad- 
ministration of  medicine. 

There  are  certain  symptoms  which  should  warn  the 
attendant  of  danger,  and  which  often  precede  death. 
When  any  of  these  are  present  they  should  be  reported  to 
the  physician.  They  are  :  partial  or  complete  uncon- 
sciousness, slow  and  labored,  rapid,  shallow,  or  irregular 
breathing,  increased  weakness  and  rapidity  of  heart  or 
pulse,  cold  hands  and  feet.  Picking  at  the  bedclothes, 
or  at  imaginary  objects  in  the  air,  or  vacant  staring,  are 
bad  symptoms. 

The  Care  of  Patients  in  a  Condition  of  Dementia. — It  is 
to  be  remembered  that  dementia  may  be  either,  a  condi- 
tion of  chronic  insanity  without  recovery,  or  a  less  per- 
manent state  of  mental  enfeeblement  following  the  acute 
attack,  and  from  which  recovery  may  be  hoped.  In  the 
first  of  these  conditions  there  is  little  to  be  done  except 
to  care  for  the  patient.  Many  are  able  to  do  some  work, 
and  should  be  allowed,  encouraged,  and  taught  to  do  it. 
Others  do  not  know  enough  to  dress,  feed,  or  care  for 
themselves.  These  must  be  kept  neatly  dressed,  taken 
to  the  table  and  their  food  prepared,  taken  to  the  bath 
and  closet,  taken  to  walk,  and  put  to  bed.  If  not  so  at- 
tended to,  they  vv^ill  degenerate  into  a  ragged,  dirty,  and 


SOME    COMMON  MENTAL    STA  TES.  65 

even  fllthy  state,  and  the  ward  upon  vv'hich  they  live  will 
be  offensive  to  the  smell.  They  should  be  frequently 
examined  for  body  vermin,  as  these  pests  are  liable  to 
breed  and  flourish  among  these  patients.  The  condition 
of  the  demented  affords  the  best  evidence  of  the  care 
given  to  the  patients  in  an  institution.  Attendants  will 
often  be  gratified  to  see  some  of  these  apparently  hope- 
less cases  greatly  improve  and  sometimes  recover. 

If  attendants  will  watch  their  patients  as  they  come  out 
of  acute  mania  or  melancholia  and  become  quiet,  they 
will  often  notice  that  they  gain  in  flesh  and  become  de- 
mented. The  dementia  may  be  but  partial,  or  so  very 
complete  that  the  patient  knows  nothing.  From  this  they 
may  gradually  go  on  to  improvement,  or  even  recovery. 
They  nped  all  the  care  demanded  by  the  confirmed  de- 
ment, and,  in  addition,  advantage  must  be  taken  of  every 
means  to  promote  recovery.  They  must  be  well  fed, 
regularly  taken  out  for  exercise,  and,  as  they  are  able, 
encouraged  to  employ  themselves.  Any  symptoms  of  a 
return  of  their  more  violent  condition,  any  failure  to 
sleep,  or  change  noticed  in  the  health  of  the  patient, 
should  be  at  once  reported. 

Care  of  the  Convalescent  Patients. — This  is  the  period 
that  precedes  recovery  from  disease.  With  the  insane  it 
is  often  a  critical  time,  and  if  not  properly  cared  for  they 
may  fail  to  get  well,  and  become  chronic  lunatics.  The 
patients,  and  frequently  their  friends,  think  they  are  well 
and  should  be  at  home.  It  is  the  attendant's  duty  to  en- 
courage the  patient,  and  to  promote  his  confidence  in  the 
physician.  They  should  not  be  told  of  their  past  condi- 
tions, or  the  disagreeable  features  of  their  sickness  called 


66  HOW  TO    CARE  FOR  THE  INSANE. 

to  mind,  and  their  last,  as  well  as  their  first  impressions 
of  the  asylum  should  be  made  pleasant.  Sometimes  there 
is  a  slight  return  of  depression  or  mania,  and  the  patient 
may  suddenly  begin  to  lose  sleep.  These  conditions 
must  be  observed  and  reported,  for  it  is  very  easy  for 
patients  who  are  recovering  to  become  as  disturbed  as 
when  they  were  first  insane,  and  to  suffer  a  relapse  from 
which  they  may  never  recover.  It  is  hardly  necessary  to 
remind  the  attendant  that  employment,  amusement,  and 
all  the  healthful  means  of  occupation  afforded  by  the 
asylum,  should  be  judiciously  allowed  these  patients. 

Sometimes  patients  feel  too  w^ell.  They  are  too  con- 
tented, happy,  and  indifferent,  and  are  very  active  in 
body  and  mind.  They  want  to  work  all  day,  from  early 
in  the  morning  until  late  at  night.  Th.ey  sing  as  they 
w^ork,  and  talk  rather  loud  and  fast.  These  patients  need 
restriction  ;  they  should  not  be  allovv^ed  to  work  too 
much,  so  as  to  overtax  their  strength.  So  long,  however, 
as  they  continue  to  gain,  and  sleep  well,  little  is  to  be 
feared,  and  they  generally  become  quieter  and  recover. 

The  Care  of  the  Epileptic  Insane. — Not  all  epileptics  are 
insane,  but  they  are  all  liable  to  insanity.  Generally  the 
most  hopeless  and  difficult  to  be  cared  for  are  brought  to 
the  asylum.  Epileptics  are  liable  to  have  fits  at  any 
time,  but  some  patients  have  them  at  night  only.  The 
attack  is  generally  sudden,  though  sometimes  patients 
have  feelings  that  warn  them  of  their  approach.  This 
may  precede  the  fit  for  a  very  short  time,  or  the  patient 
may  know  during  the  day  that  he  will  have  a  fit  during 
the  night. 

Epileptic  fits  are  accompanied  by  convulsions  and  un- 


SOME    COMMON  MENTAL   STA  TES.  6j 

consciousness,  and  are  the  type  of  all  convulsions.  The 
unconsciousness  may  be  but  momentary,  or  last  an  hour 
or  longer,  and  even  prolonged  several  days  ;  the  convul- 
sions may  be  but  the  twitching  of  a  few  muscles,  as  of 
the  face,  or  may  consist  of  the  most  terrible  writhings, 
and  last  for  several  minutes,  and  be  often  repeated. 
Sometimes  the  fits  are  ushered  in  by  a  scream. 

The  fit  itself  is  not  dangerous  to  life,  but  patients 
may  at  night  turn  their  face  downward  and  so  smother ; 
they  may  fall  from  high  places,  or  down  stairs,  or  into 
the  water,  or  into  the  fire,  and  so  injure  themselves. 
There  is  little  to  do  during  an  epileptic  attack.  Pa- 
tients should  not  be  held  to  prevent  the  convulsions,  but 
so  that  they  shall  not  injure  themselves.  A  pillow  should 
be  placed  under  the  head  and  the  bands  about  the  neck 
loosened.  The  nurse  is  sometimes  given  remedies  which, 
if  properly  administered  when  the  attack  is  felt  to  be 
coming  on,  may  ward  off  the  fit.  Nitrite  of  amyl  in  small 
'glass  pearls  is  a  common  remedy.  It  is  to  be  broken 
in  a  handkerchief  and  several  strong  breathfuls  taken. 

At  their  best,  epileptics  are  cross,  irritable,  quick-temp- 
ered, unreasonable,  and  quarrelsome,  and  they  will  often 
give  a  blow  at  slight,  or  even  for  no  provocation.  After 
a  fit  they  are  frequently  dangerous  and  always  require 
guarded  care  and  watching.  As  has  been  said,  they  may 
soon  recover  their  natural  condition,  or  remain  in  a  more 
or  less  prolonged  state  of  unconsciousness,  or  they  may 
pass  into  a  condition  that  appears  natural,  but  in  which 
they  have  but  little  or  no  appreciation  of  their  situa- 
tion or  surroundings,  or  remember  afterwards  what  they 
do.     In  these   states   they  may,  without  warning,  make 


68  HOW  TO    CARE   FOR  THE  INSANE. 

violent  assaults,  commit  murder  or  suicide,  or  set  things 
on  fire.  Sometimes  they  do  outrageous  acts,  such  as 
beating  their  own  children  to  death  against  the  wall,  or 
mutilating  them,  or  roasting  them  to  death  on  the  stove. 
Many  often  suffer  from  hallucinations  or  illusions  of 
sight  or  hearing,  and  have  delusions  of  impending  harm 
or  assaults,  and  think  they  must  defend  themselves. 

Care  of  Patients  with  Paresis. — This  is  a  form  of 
insanity  characterized  by  progressive  dementia  and 
increasing  bodily  enfeeblement  and  paralysis.  The  par- 
alysis is  partial,  not  complete  ;  the  patient's  walk  is  feeble, 
unsteady,  and  shuffling  ;  the  hands  are  tremulous,  lose 
their  fineness  of  touch  and  ability  to  do  w^ork  and  write  ; 
there  is  twitching  in  the  muscles  of  the  tongue  and  about 
the  mouth,  and  the  speech  is  thick  and  indistinct.  As 
the  disease  progresses  the  patient  becomes  helpless,  bed- 
ridden, wet,  and  filthy.  The  result  is  always  death. 
Convulsions  like  those  of  epilepsy  are  liable  to  occur, 
from  which  the  patients  may  rally,  or  in  which  they  may 
die  or  linger  a  few  days.  In  the  earlier  stages  the 
patients  are  often  strong,  and  controlled  by  delusions  and 
hallucinations  that  make  them  violent.  Sometimes  they 
are  simply  good-natured  and  easily  managed.  They  gen- 
erally have  very  exalted  and  extravagant  delusions,  and 
are  without  appreciation  of  their  condition  or  surround- 
ings, and  are  irritated  at  the  control  of  the  asylum,  and 
on  account  of  their  unreasonableness  they  can  rarely  be 
allowed  the  liberty  others  enjoy. 

Paretics  often  eat  ravenously  and  rapidly,  they  stuff 
their  mouths  full  of  food  and  so  choke  themselves. 
Their  condition   of   paralysis   may  render  them  uncon- 


SOME   COMMON  MENTAL   STATES.  69 

scious  of  danger  and  powerless  to  help  themselves.  The 
care  needed  by  bedridden,  filthy  paretics  is  practically 
the  same  demanded  by  helpless  paralytics,  the  old,  feeble, 
or  demented  class,  and  all  others  who  cannot  care  for 
themselves. 

Care  of  the  ParalytiCy  Helpless^  Bedridden,  and  Filthy 
Patients. — There  are  many  patients  in  an  asylum  who 
are  indifferent  to  all  the  wants  of  nature,  who  wet  and 
dirty  themselves.  Some  of  these  patients  are  bedridden  ; 
some  are  about  the  ward,  but  demented  ;  some  are  vio- 
lent and  maniacal,  and  some  from  delusions  make  their 
persons  and  rooms  as  filthy  as  possible.  Much  can  be 
done  with  many  of  these  patients  by  regularly  taking  them 
to  the  closet,  and  their  bad  habits  may  in  this  way  be 
broken  up.  Patients  of  this  class  should  be  visited  dur- 
ing the  evening,  attended  to  frequently  by  the  night 
watch,  and  seen  the  first  thing  in  the  morning.  Patients, 
when  dirty,  should  be  thoroughly  washed  and  carefully 
dried.  Their  beds  should  be  cleaned  and  changed,  and 
during  the  day  clean  clothing  should  be  given  them  as 
often  as  required. 

The  greatest  danger  that  comes  from  not  keeping 
patients  clean  is  the  formation  of  bed-sores. 

Bed- Sores. — Bed-sores  occur  in  patients  long  confined  to 
bed,  and  who  suffer  from  exhaustive  diseases.  Paralytics 
and  paretics  are  particularly  liable  to  them,  the  diseased 
condition  of  the  nerves  allowing  the  tissues  to  break  down 
easily.  Sometimes  the  fingers  or  toes  of  a  paretic  be- 
come gangrenous  or  large  surfaces  of  the  skin  die,  and 
sometimes  deeper  tissues  slough  away  rapidly.  These 
conditions  may  come  on  in  a  day  or  a  night. 


70  HOW  TO    CARE  FOR  THE  INSANE. 

Patients  who  are  wet  and  dirty  are  more  liable  to  have 
bed-sores.  They  will  always  appear  in  a  bedridden 
paretic  in  a  few  days  if  not  kept  perfectly  clean.  They 
most  frequently  occur  over  bony  projections  where  the 
weight  comes  in  lying,  as  upon  the  hips,  back,  or 
shoulders. 

Such  patitents,  should,  if  possible,  be  made  to  sit  up  sev- 
eral hours  every  day,  or  placed  first  on  one  side,  then  on  the 
back,  and  then  on  the  other  side.  If  it  can  be  done,  they 
should,  as  they  lie  in  bed,  rest  their  hips  on  an  inflated 
rubber  ring,  and  if  the  skin  is  red  the  part  should  be 
bathed  in  diluted  alcohol.  After  being  bathed  and  dried 
the  skin  about  the  hips  should  be  dusted  with  some  dry 
powder.  Powdered  oxide  of  zinc  is  perhaps  the  best, 
but  ordinary  corn-starch  flour  is  valuable  and  serves  a 
good  purpose.  Insane  patients  frequently  will  resist  all 
care  and  every  effort  to  prevent  bed-sores,  tearing  off  the 
bandages  and  dressings  and  picking  and  irritating  the 
sores.  •■ 

Bed-sores  should  never  be  allowed  to  come  because  of 
want  of  attention  or  cleanliness,  but  there  are  conditions 
in  which  they  will  appear  in  spite  of  every  preventive. 

Bed-sores  once  formed  should  be  treated  as  ulcers 
and  according  to  the  direction  of  the  physician. 


CHAPTER  IX. 

SOME    OF    THE    COMMON    ACCIDENTS    AMONG    THE    INSANE, 
AND    THE    TREATMENT    OF    EMERGENCIES. 

'T^HE  insane,  like  others,  may  suffer  from  almost  ^ny 
^  accident.  It  is  not  intended  to  treat  of  all  acci- 
dents, nor  hoAV  to  care  for  every  emergency.  This  is  so 
large  a  subject  as  to  demand  a  separate  text-book,  and 
there  are  several  excellent  ones,  that  attendants  would 
do  well  to  read.  But  there  are  among  the  insane  certain 
kinds  of  accidents  that  are  likely  to  occur,  certain  classes 
who  are  liable  to  receive  accidents,  and  certain  emergen- 
cies that  frequently  have  to  be  cared  for  by  the  attend- 
ant, and  these  will  be  described.  Every  injury  received 
by  a  patient  should  be  immediately  reported  to  a 
physician. 

Attendants,  in  the  care  of  the  insane  should  always 
remember  the  liability  to  accident  and  guard  against  it. 
The  old,  the  feeble,  the  paralytic,  and  paretic  need 
special  care.  They  are  weak,  easily  pushed  over,  or 
stumble  and  fall,  and  they  cannot  break  the  weight  of 
their  fall,  or  so  defend  themselves  ;  they  are  irritable, 
childish,  and  often  provokingly  troublesome  to  the  other 
patients,  and  their  bones  seem  to  be  easily  fractured. 
Some  injuries  are  self-inflicted,  some  come  to  the  patient 
in  consequence  of  his  own  or  others'  violence,  and  some, 
as  has  been  said,  from  the  very  weakness  of  the  patient. 

71 


J 2  HOW  TO   CARE  FOR  THE  INSANE. 

Care  of  Fractured  Bones.— Kxiy  of  the  bones  may  be  frac- 
tured, and  from  slight  cause.  The  bones  most  frequently 
fractured  are  :  the  collar  bones,  the  ribs,  the  bones  of  the 
forearm  just  above  the  wrist,  the  bones  of  the  lower  leg 
and  of  the  thigh.  This  last  bone,  the  femur,  is  among 
old  people  most  frequently  broken  at  its  neck,  which  is 
the  constriction  of  the  bone  just  below  the  rounded  end 
that  fits  into  the  joint  at  the  hip. 

Fractures  should,  as  much  as  possible,  be  let  alone  till 
the  physician  comes.  The  parts  should  be  kept  quiet  so 
as  not  to  cause  unnecessary  pain,  and  do  further  injury. 
By  rough  handling  it  is  very  easy  to  push  a  fragment 
of  bone  through  the  skin,  thus  making  a  simple  fracture 
a  compound  one.  When  a  rib  is  fractured  a  sharp  end 
may  pierce  the  skin  or  the  lung  ;  either  complication  is 
serious.  If  the  lung  is  injured  the  sputa  will  be  bloody, 
and  the  appearance  of  such  a  condition  should  be  at 
once  reported.  Sometimes  patients  are  violent  after  the 
injury  and  need  to  be  firmly  held,  and  sometimes  they 
have  to  be  carried  to  the  ward  from  the  outside,  or 
placed  upon  a  bed.  Always  carry  the  fractured  limb  as 
well  as  the  patient. 

If  temporary  splints  are  put  on  do  not  make  them  too 
tight,  and  loosen  them  from  time  to  time  as  needed. 
The  extremities  sometimes  swell  rapidly  after  a  fracture, 
and  the  splints  may  so  stop  the  circulation  that,  in  a 
few  hours,  gangrene  may  be  caused  by  them.  Besides, 
many  patients  cannot  tell  us  if  the  part  is  swollen  or 
painful. 

The  Care  of  Wounds, — Bites.  Insane  patients  often 
bite  others  and  penetrate  the  skin.     They  may  be  very 


ACCIDENTS  AMONG  THE  INSANE.  73 

angry,  their  mouths  foul  and  running  with  saliva,  and 
this  irritating  substance  introduced  into  the  wound  by 
the  teeth  may  set  up  an  ugly  inflammation.  The  wound 
should  be  immediately  and  thoroughly  washed.  It  should 
be  well  cleaned  wdth  a  wet  sponge  or  cloth,  and  soaked  in 
warm  water.  A  good  after-dressing  is  powdered  iodo- 
form, sprinkled  over  the  v/ound. 

Woimds  of  the  Head. — These  wounds  are  quite  com- 
mon. They  should  be  thoroughly  washed  and  cleaned 
from  dirt  and  hair.  Hemorrhage  may  be  controlled  by 
continued  pressure  upon  the  bones  of  the  skull,  and  if  an 
artery  is  cut,  it  can  in  this  way  be  kept  from  bleeding  till 
the  physician  arrives.  Most  wounds  of  the  head,  even 
though  large,  generally  heal  quickly,  but  the  most  trifling 
ones  may  assume  serious  proportions,  and  even  prove 
fatal.  If  within  two  or  three  days  heat,  pain,  redness, 
and  swelling  appear,  pus  is  probably  forming  beneath 
the  scalp,  and  this,  within  a  f ev/  hours,  may  spread  under 
a  large  surface  and  do  serious  injury,  or  erysipelas  may 
be  set  up. 

Injuries  f^^om  Blows  on  the  Head. — Persons  are  some- 
times stunned  by  blows  on  the  head.  They  should  be 
placed  in  bed  with  the  head  elevated,  and  kept  perfectly 
quiet  till  the  doctor  comes.  Efforts  should  not  be  made 
to  arouse  them,  they  should  not  be  given  liquor  of  any 
kind,  but  ice  may  be  applied  to  the  head.  The  danger 
to  be  feared  is  from  the  skull  being  fractured,  or  from 
bleeding  vessels  inside  of  the  skull.  Either  of  these  con- 
ditions may,  by  pressure  upon  the  brain,  cause  uncon- 
sciousness, paralysis,  and  death. 

The  Care  of  a  Cut   Throat, — Patients  may  cut  their 


74  HO  IV  TO    CARE  FOR  THE  INSANE. 

throats  from  ear  to  ear  and  do  really  little  injury,  or  they 
may  make  a  small  stabbing  wound  and  divide  a  large 
blood-vessel  and  die  almost  immediately,  or  they  may 
cut  the  windpipe  and  not  cut  the  blood-vessels.  The 
windpipe  you  can  notice  upon  yourselves  as  a  large,  stiff 
tube,  prominently  situated  in  the  middle  and  front  of  the 
neck  ;  the  blood-vessels  are  together  on  each  side  of  the 
Vi^indpipe,  and  situated  quite  deep  down  among  the 
muscles,  and  the  carotid  artery  may  be  felt  beating  by 
the  finger.  Little  can  be  done  by  the  attendants  to  stop 
the  flow  of  blood,  even  if  the  great  blood-vessels  are  not 
cut.  The  head  should  be  kept  bent  forward  and  the 
chin  pressed  against  the  chest. 

After  the  physician  has  dressed  the  wound,  constant 
watching  day  and  night  may  be  required  to  prevent  the 
patient  tearing  off  the  bandages  and  reopening  it.  This 
same  rule  of  watchfulness  applies  to  the  after-care 
needed  to  be  given  to  many  cases  of  fracture,  and  other 
serious  injuries  among  the  insane. 

Care  of  Wounds  of  the  Extremities  with  Hemorrhage. — 
The  hemorrhage  from  most  simple  wounds  involving  the 
cutting  o£  skin  and  fiesh  or  small  arteries,  can  usually  be 
controlled  by  direct  and  continued  pressure.  This  may 
be  done  by  a  pad  made  of  cloth,  packed  and  pressed  into 
the  v/ound,  or  lint  may  be  used  in  the  same  v/ay.  Water 
as  hot  as  can  be  borne  poured  into  the  wound  will  fre- 
quently stop  a  hemorrhage  when  other  means  fail  ;  cold 
applications  and  ice  are  also  useful.  If  dirty,  a  wound 
should  be  thoroughly  cleaned,  being  washed,  and,  if 
necessary,  soaked  in  warm  water.  Iodoform  sprinkled 
so  as  to  cover  wounds,  i.s  the  best  dressing  for  all  attend- 


ACCIDENTS  AMONG  THE   INSANE.  75 

ants  or  nurses  to  apply,  while  awaiting  directions  from  a 
physician.  It  keeps  them  clean,  promotes  healing,  and 
lessens  the  danger  of  inflammation  or  the  formation  of 
pus. 

Vv^hen  the  arteries  of  the  extremities  arc  cut,  pressure 
should  be  made  on  the  large  artery  leading  to  the  part. 
When  the  wound  is  high  up  on  the  arm,  pressure  is  made 
by  the  fingers  or  a  padded  key  upon  the  artery  that  lies 
back  of  the  collar  bone,  and  the  attempt  should  be  made 
to  press  it  against  the  bone.  This  is  a  difiicult  thing  to 
do,  but  nevertheless  it  should  be  attempted.  When  the 
wound  is  lower  down,  pressure  is  to  be  made  by  the 
fingers  on  the  inner  side  of  the  upper  arm,  at  about  the 
middle  point  and  against  the  bone.  The  artery  runs 
downward,  near  the  inner  border  of  the  biceps  muscle, 
which  is  the  large,  bulging  muscle  of  the  upper  arm,  and 
can,  with  a  little  care,  be  felt  beating  by  the  fingers. 
Patients  in  breaking  glass  often  cut  one  or  both  arteries 
at  the  wrist-joint  v/here  the  pulse  is  felt.  These  are  large 
and  bleed  rapidly,  and  when  cut  need  the  care  just  de- 
scribed. 

When  the  artery  in  the  leg  is  wounded,  pressure  is  to 
be  made  on  the  inner  side  of  the  thigh,  just  below  the 
groin.  The  position  of  these  large  arteries,  and  how  to 
press  against  the  bone,  is  best  learned  by  instruction  and 
demonstration  from  a  physician,  and  with  a  little  practice 
attendants  will  be  able  to  easily  and  successfully  do  the 
act. 

It  is  very  tiresome  to  continue  pressure  with  the  fingers 
for  a  long  time,  and  attendants  should  relieve  one  another 
till  the  physician  com  23. 


'J 6  HOW  TO   CARE  FOR  THE  INSANE. 

The  Care  of  Sprains. — Sprains  are  a  common  accident 
and  easily  produced.  The  great  end  of  treatment  is  to 
keep  the  sprained  joint  quiet.  If  the  ankle  or  knee  is 
sprained,  the  patient  should  be  carried  to  bed.  Perhaps 
the  best  early  treatment,  aiid  the  one  that  gives  the 
greatest  relief  to  pain,  is  to  place  the  joint  in  a  tub  of 
water  as  hot  as  can  be  borne,  and  keep  it  hot  by  pouring 
in  more.  The  part  should  be  kept  in  the  water  until  it  is 
parboiled.  The  skin  of  some  feeble  or  paralytic  patients 
is  easily  scalded,  and  some  cannot  tell  when  it  is  too  hot ; 
the  water  therefore  should  never  be  uncomfortable  to  the 
hand  of  the  attendant. 

Care  of  Patients  Choking. — This  is  a  frequent  accident, 
and  in  order  to  know  what  to  do  when  it  occurs,  it  is 
necessary  to  have  a  knowledge  of  the  air  passages  of  the 
throat. 

We  breathe  through  the  mouth  and  nose.  They  open 
into  a  common  passage,  the  pharynx,  which  can  be  seen 
by  looking  into  the  mouth,  lying  back  of  the  tonsils. 
Passing  downward,  it  divides  by  branching  into  two 
tubes  ;  one  the  windpipe,  which  is  in  front,  behind  it  is 
the  oesophagus  or  gullet. 

The  point  of  division  is  just  beyond  the  tongue,  and  is 
almost  within  reach  of  the  forefinger  when  crowded  into 
the  mouth. 

The  air  we  breathe  passes  through  the  mouth  and  nose 
to  the  pharynx,  thence  to  the  lungs  by  the  windpipe. 
The  food  we  eat  passes  from  the  mouth  to  the  pharynx, 
and  thence  to  the  stomach  by  the  oesophagus. 

There  is  at  the  opening  of  the  windpipe  a  cover,  the 
epiglottis,  which  is  generally  open,  but  which  closes  when 


ACCIDENTS  AMONG    THE  INSANE.  yj 

food  is  swallowed  and  helps  to  keep  food  from  entering. 
When  a  substance  touches  the  opening  of  the  windpipe, 
we  instantly  cough  to  expel  it. 

A  person  may  choke,  when  the  mouth  and  the  pharynx 
back  of  it  are  filled  with  food  ;  or  when  a  piece  is  lodged 
in  the  wind-pipe,  or  a  large  piece  in  the  oesophagus  at  the 
point  of  division,  and  which  crowds  upon  the  windpipe,  or 
covers  the  opening.  Food  gets  into  the  windpipe,  by 
being  drawn  in  by  a  sudden  and  unexpected  inspiration 
of  air.  This  may  happen  while  eating  or  in  vomiting 
solid  food.  With  this  accidental  exception  all  breathing 
stops  during  the  act  of  swallowing. 

Some  patients,  from  paralysis,  especially  paretics,  do 
not  feel  food  when  it  is  lodged  in  the  throat  ;  others, 
from  great  dementia,  may  not  know  when  they  are  chok- 
ing, and  show  no  emotional  signs  of  distress.  Paretics 
are  particularly  liable  to  bolt  their  food,  and  cram  the 
mouth  and  throat  full. 

The  symptoms  of  choking  are  immediate,  and  if  no 
relief  is  obtained,  the  sufferer  will  die  in  a  few  minutes. 
If  the  patient  knows  any  thing,  he  wid  show  immedi- 
ate signs  of  distress,  violent  but  ineffectual  attempts  to 
breathe,  and  the  face  quickly  becomes  a  dark  blue  color, 
from  the  accumulation  of  carbonic  acid  in  the  blood. 

Immediate  effects  should  be  made  to  remove  the  ob- 
struction, and  continued  until  the  physician  arrives,  who 
is  to  be  sent  for  at  once.  Whatever  is  in  the  mouth 
and  throat  can  be  easily  removed  by  the  fingers  ;  the 
forefinger  should  then  be  crowded  down  the  throat 
to  feel  for  other  obstructions,  care  being  taken  not  to 
push  a  piece  of  food  into  the  windpipe.     If  any  thing  is 


78  HOW  TO   CAKE  FOR  THE  INSANE. 

felt,  it  can  sometimes  be  pulled  out  by  the  fingers,  or  a 
hair-pin  may  be  straightened  and  bent,  or  a  piece  of  wire, 
and  an  effort  made  to  fish  it  out.  When  in  the  gullet  and 
beyond  the  fingers,  it  may  be  pushed  into  the  stomach 
by  a  feeding-tube.  Artificial  respiration  may  be  needed, 
but  attendants  must  remember  it  is  of  no  use  until  the 
obstruction  to  breathing  is  removed. 

Marbles,  coins,  buttons,  pieces  of  pencils,  needles, 
pins,  and  fish-bones,  are  frequently  swallowed.  The 
physician  should  be  informed  at  once. 

Directions  how  to  Perform  Ai'tificial Respiration. — What 
is  to  be  done  must  be  done  quickly  ;  tight  clothing  about 
the  neck  and  chest  must  be  removed,  and  the  mouth 
should  be  cleaned  of  dirt,  water,  or  any  obstruction  to  the 
flow  of  air.  The  body  is  then  laid  out  flat  on  the  back, 
covered,  if  possible,  with  light  warm  blankets,  and  some 
article  should  be  folded  and  placed  under  the  shoulders, 
so  as  to  raise  them  three  or  four  inches.  The  mouth  must 
be  kept  open,  and  the  tongue  pulled  well  forward,  as  it  is 
liable  to  fall  backwards,  and  cover  the  opening  of  the 
wind-pipe.  One  person,  kneeling  behind  the  head, 
should  grasp  each  arm  at  the  elbow,  and,  draw  thein 
steadily  around  so  that  the  arms  will  meet  above  the  head. 
A  strong  pull  should  be  made  upon  them,  and  they 
should  be  held  a  few  seconds.  These  movements  elevate 
the  ribs  and  enlarge  the  chest  and  produce  an  inspira- 
tion. 

The  arms  are  then  to  be  brought  to  the  side,  and 
pressed  strongly  against  the  lower  ribs.  This  last  move- 
ment drives  the  air  out  of  the  lungs,  and  makes  an  expira- 
tion.   These  manipulations  should  be  repeated,  slov/ly  and 


ACCIDENTS  AMONG    THE  INSANE.  79 

regularly,  about  sixteen  times  a  minute,  and  should,  when 
there  is  the  slighest  hope  of  life,  be  continued  at  least 
thirty  minutes.  The  heart  should  be  listened  to,  in 
order  to  hear  if  it  still  beats.  Warmth,  by  hot-water 
bags,  bricks,  and  soapstones  should  be  secured,  care 
being  taken  not  to  burn  the  skin.  The  limbs  may  be 
gently  rubbed  with  warm  cloths,  though  it  is  not  so  im- 
portant as  some  well-meaning  people  think.  The  rub- 
bing should  be  towards  the  heart. 

As  the  breathing  begins,  it  should  be  still  aided  by  the 
artificial  means  as  long  as  necessary.  When  the  patient 
can  swallow,  teaspoonful  doses  of  brandy  or  whiskey,  to 
two  or  three  of  water,  may  be  given  and  repeated  several 
times.  As  soon  as  possible  the  patient  should  be  put  in 
a  warm  bed,  and  milk  and  light  food  given. 

Care  of  Patients  when  First  Bitrned, — When  a  patient's 
clothing  is  first  on  fire,  dash  v/ater  over  him  if  ne^r  at 
hand,  if  not  v/rap  him  in  a  blanket  or  some  heavy  woollen 
garment,  and  smother  the  fire.  Then  unroll  the  patient 
and  extinguish  the  smouldering  pieces  of  clothing.  The 
clothing  must  be  cut  and  clipped  off.  Great  care  must 
be  taken  not  to  tear  open  the  blisters.  If  any  applica- 
tion is  made,  it  may  be  by  linen  cloths  soaked  in  sv/eet 
or  castor  oil,  or  equal  parts  of  linseed  oil  and  lime-water, 
or  a  layer  of  flour  and  molasses  may  be  applied  over  the 
burned  surface.  These  bland  substances  act  largely  by 
excluding  the  air,  which,  if  blowing  ever  so  quietly,  is 
always  painful  and  irritating,  and  they  also  protect  the 
wound  from  the  irritation  of  the  bed  and  body  clothing. 
Burns  from  scalding  are  practically  treated  in  the  same 
v/ay  as  burns  from  fire. 


80  HOW   TO    CARE  FOR    THE  INSANE. 

Care  of  Frost-bites. — Toes,  fingers,  ears,  and  noses  are 
most  frequently  frozen.  They  will  sometimes  freeze  in  a 
few  minutes  on  a  very  cold  day.  After  a  part  is  frozen 
there  is  no  feeling  of  cold  or  pain,  and  it  looks  perfectly 
white,  and  is  so  stiff  it  may  be  broken. 

Persons  who  are  frost-bitten  should  not  be  taken  into 
a  warm  room.  They  should  be  left  in  a  cool  room,  and 
the  frozen  part  rubbed  with  cold  vv^ater,  or  ice,  or  snow. 
As  these  last  melt  they  melt  the  frozen  flesh.  If  the  parts 
are  thawed  too  quickly  gangrene  is  liable  to  follow. 

Care  of  Patients  in  States  of  Unconsciousness. — This  is 
not  an  accident,  but  a  frequent  emergency.  The  medical 
word  for  unconsciousness  is  co7na.  It  may  be  partial  or 
complete,  may  come  on  suddenly  or  slowly,  or  may  be 
accompanied  by  convulsions  or  paralysis.  The  more 
frequent  causes  of  coma,  are  epilepsy,  the  convulsions  of 
paresis,  blov/s  on  the  head,  hemorrhage  in  the  brain  or 
apoplexy,  some  diseases  of  the  brain,  sunstroke,  and 
some  poisons. 

When  coma  comes  on,  attendants  should  observe,  if  it 
is  slow  or  sudden  ;  if  the  patient  complains  of  pain  in  the 
head  ;  if  the  respirations  are  changed,  and  how  ;  the  condi- 
tion of  the  pupils,  whether  large,  contracted,  uneven,  or 
changeable  ;  if  the  mouth  and  face  are  drawn  to  one  side  ; 
if  there  is  any  paralysis  of  the  arms  or  legs  ;  if  there  are 
any  convulsions,  or  twitching  of  muscles  ;  if  the  patient 
can  b'fe  aroused,  and  from  time  to  time  observe  and  count 
the  pulse. 

Apoplexy  is  a  term  that  is  much  used,  and  is  a  condi- 
tion of  coma,  caused  by  pressure  on  the  brain.  This 
organ  is  in  a  tight,  rigid  box,  the   skull.     If  the  fluid  of 


ACCIDENTS  AMONG    THE  INSANE,  8 1 

the  brain  is  much  increased,  or  blood-vessels  ruptured, 
pressure  is  the  result,  and  the  soft  tissues  yield,  rather 
than  the  bony  covering.  This  pressure  may  destroy  or 
injure  the  cells  and  fibres,  and  so  interfere  with  the  func- 
tion of  the  part.  Another  way  that  apoplexy  occurs  is 
by  plugging  of  an  artery  of  the  brain,  so  that  it  cannot 
deliver  blood  to  the  part  to  which  it  goes,  and  conse- 
quently the  part  loses  its  ability  to  perform  its  function. 
The  plugging  is  most  frequently  due  to  a  sm.all  clot  float- 
ing in  the  blood,  and  which  is  usually  formed  in  the 
heart. 

Paralysis  and  apoplexy  are  often,  through  ignorance, 
used  synonymously,  but  they  really  mean  very  different 
conditions.  Paralysis  is  a  loss  of  power  of  contracting  a 
muscle,  due  to  disease  or  injury  of  the  nervous  system  ; 
it  frequently  follows  or  is  associated  with  apoplexy. 

In  the  case  of  apoplexy,  and  most  conditions  of  coma, 
there  is  generally  little  for  the  attendant  to  do.  The 
patient  should  be  put  to  bed,  with  light  coverings,  and 
the  head  raised  on  pillows.  Do  not  annoy  the  patient  by 
trying  to  rouse  him,  and  do  not  give  stimulants. 

Care  of  Sunstroke. — A  sunstroke  is  a  very  serious 
condition,  and  when  it  occurs,  requires  immediate  efforts 
to  save  the  life  of  the  one  suffering  from  it.  It  generally 
comes  on  suddenly,  the  patient  first  complaining  of  the 
head  ;  he  soon  becomes  unconscious,  the  skin  hot  and 
dry,  and  the  pulse  full  and  bounding.  The  treatment 
consists  of  taking  the  patient  to  a  cool,  shaded  place,  re- 
moving all  unnecessary  clothing,  applying  ice  or  cold 
water  to  the  head,  and  bathing  or  sponging  the  body  in 
cold    water.     If  the   patient   recovers,    the    temperature 


82  HOW    TO    CARE   FOR    THE   INSANE. 

will  fall  under  this  treatment.  If  the  heart  begins  to  fail, 
or  the  pulse  becomes  weak  or  fluttering,  small  doses  of 
whiskey  and  water  may  be  given  and  repeated. 

Patients  should  not  be  taken  out  in  the  fields  nor 
exposed  places  on  very  hot  days,  except  as  ordered  by 
the  physicians  ;  they  should  v/ear  light  clothing  and  a 
straw  hat ;  if  permitted  to  go  out,  they  should  not  over- 
work, and  should  be  allowed  frequently  to  rest  in  the 
shade.  Patients  are  easily  injured  by  working  in  the 
sun  ;  headache  caused,  recovery  retarded,  and  bad 
symptoms  brought  back,  without  having  the  alarming 
conditions  of  sunstroke. 

Unconsciousness  from  Poisoning. — Opium  and  its  prepa- 
rations, including  morphine,  chloral,  and  the  two  extracts 
of  hyoscyamus,  now  so  much  employed  in  asylums,  name- 
ly, hyoscine  and  hyoscyamine,  are  medicines  frequently 
given,  that  poison  in  over-doses  and  produce  coma. 

These  medicines  and  their  effects  will  be  described  in 
the  next  chapter,  and  at  the  same  time  the  symptoms  of 
poisoning  by  them,  and  the  treatment. 

Poisoning. — Poisonous  drugs  are  not  kept  upon  the 
v/ards.  Attendants  frequently  have  strong  ammonia  in 
their  rooms  to  clean  their  clothing,  and  a  patient  may 
get  it  and  drink  it.  It  is  a  strong  alkali,  and  burns  th» 
throat  and  mouth.  Vinegar  is  the  best  ready  antidote, 
but  should  be  given  immediately  or  not  at  all.  Soft  soap 
is  a  strong  alkali,  and  if  eaten  becomes  an  irritating  poi- 
son.    Again  vinegar  is  the  best  antidote. 

The  best  antidotes  for  acids  are  soda,  lime-water,  soap- 
suds, and  chalk  ;  for  alkalies,  weak  acids,  such  as  lemons, 
oranges,  vinegar,  or  cider.     Olive  oil,  eggs,  and  mucilagi- 


ACCIDENTS  AMONG    THE   INSANE,  83 

nous  drinks  are  the  most  bland  and  soothing  remedies 
to  give.  To  vomit  a  person  who  has  taken  poison,  give 
a  pint  or  a  quart  of  lukewarm  water  ;  to  it  may  be  added 
one  or  two  teaspoonfuls  of  mustard.  Syrup  of  ipecac 
is  a  common  remedy,  the  dose  is  a  teaspoonful,  and  re- 
peated in  ten  minutes  if  necessary.  It  assists  vomiting 
to  tickle  the  throat  with  a  finger  or  a  feather.  If  after 
poisoning  there  is  depression  or  approaching  coma,  very 
strong  tea  or  coffee  is  the  best  stimulant,  and  it  is  as  well 
an  antidote  to  many  poisons.  If  the  heart  and  pulse  are 
very  weak,  whiskey  diluted  with  water  may  be  given  and 
repeated. 

Injury  from  Eating  Glass. — Patients  sometimes  eat 
glass.  This  injures  by  the  edges  cutting  and  inflaming 
the  walls  of  the  stomach  and  intestines.  This  may  be  so 
severe  as  to  cause  death.  In  the  treatment  do  not  give 
an  emetic  or  a  cathartic.  Such  food  as  has  a  tendency 
to  constipate  the  bowels,  and  such  as  will  also  enclose 
the  glass  and  coat  its  sharp  edges,  is  to  be  given.  Pota- 
toes, especially  sweet,  oatmeal,  or  thick  indian-meal  pud- 
ding, are  appropriate.  Cotton,  which  is  generally  at  hand, 
will,  if  swallowed,  engage  the  glass  in  its  fibres,  and  so 
protect  from  injury. 

Injury  with  Needles. — This  is  a  self -injury,  but  it  may 
be  severe  and  require  immediate  attention.  Patients 
may  open  a  vein  or  an  artery  with  a  needle,  or  plunge  it 
into  the  eye.  But  the  more  common  way  is  for  a  patient 
to  stick  many  needles  under  the  skin,  sometimes  to  the 
number  of  several  hundred.  Sometimes  patients  intro- 
duce them  near  the  heart  or  lungs,  and  as  a  needle  will 
often  "  travel  "  when  in  the  flesh,  it  may  work  its  way 


84  HOW   TO   CAFE  FOR    THE  INSANE. 

into  a  deeper  part,  and  so  a  number  get  into  the  lungs  or 
the  heart,  causing  death.  Within  a  few  weeks  I  saw  two 
needles  taken  from  a  man's  heart,  who  died  in  conse- 
quence of  their  presence  there.  An  attempt  or  desire  to 
so  injure  one's  self  should  be  guarded  against  by  the 
attendants,  and  if  accomplished  should  be  at  once 
reported  to  the  physician,  that  efforts  may  be  made  to 
extract  the  needle. 


CHAPTER  X. 

SOME  SERVICES  FREQUENTLY  DEMANDED  OF  ATTENDANTS, 
AND    HOW    TO    DO    THEM. 

'T^HE  Administration  and  Effect  of  Medicine. — The 
only  proper  way  of  giving  medicine  is  by  using 
standard  weights  and  measures.  Dropping  medicine,  or 
using  spoons  or  cups,  is  not  sufficiently  accurate.  A 
drop  may  be  half  a  minim,  or  as  large  as  two  or  even 
three.  The  modern  teaspoon  holds  ninety  or  more  min- 
ims, and  a  tablespoon  more  than  half  an  ounce. 

Medicines  are  introduced  into  the  system  through  the 
stomach,  the  lungs,  the  rectum,  the  skin,  or  by  being 
injected  into  the  tissues,  under  the  skin.  They  are 
either  local  or  general  in  their  effects.  A  blister  or  a 
poultice  is  a  local  remedy,  so  is  an  emetic,  that  acts  by 
irritating  the  walls  of  the  stomach.  General  medicines 
are  absorbed  into  the  blood,  and  carried  to  different 
parts  of  the  body. 

The  following  are  a  few  of  the  reasons  for  which  med- 
icine is  given :  to  relieve  pain,  to  give  sleep,  to  pro- 
duce vomiting,  to  check  vomiting,  to  move  the  bowels, 
to  check  diarrhoea,  to  assist  digestion,  to  produce  a 
greater  or  diminished  flow  of  urine,  to  increase  the 
perspiration,  to  increase  the  red  blood  corpuscles,  to 
check  hemorrhage,  to  regulate  the  action  of  the  heart, 

85 


86  HOW  TO    CARE  FOR  THE   INSANE. 

to  overcome  the  effects  of  poison,  to  increase  or  diminish 
the  amount  of  blood  in  the  brain,  to  control  spasm,  to 
diminish  the  temperature  in  fever. 

In  some  cases  the  effect  desired  a.nd  expected  from  a 
medicine  given  to  a  patient  is  told  to  the  attendant,  who 
should  closely  observe  and  be  able  to  report  the  result. 
Sometimes  medicines  are  left  in  the  hand  of  the  attend- 
ant, to  give  in  repeated  doses,  at  stated  intervals,  till  a 
desired  effect  is  produced.  The  attendant  is  also 
instructed  to  watch  for  certain  symptoms  which  show 
that  the  medicine  is  doing  harm,  when  it  is  to  be  discon- 
tinued. An  attendant,  who  has  studied  and  learned, 
"how  and  what  to  observe  "  in  his  patient,  will  be  able  to 
give  intelligently  any  medicine  ordered  by  a  physician. 

Sometimes  medicines,  given  in  large  or  long-continued 
doses,  cause  symptoms  that  an  attendant  should  notice 
and  report  to  the  physician  ;  some  of  these  are,  eruptions 
on  the  face  and  body,  puffiness  about  the  eyes,  irritation 
and  running  of  the  eyes,  a  metallic  taste  in  the  mouth, 
bleeding  of  the  gums  or  soreness  of  the  teeth  and  pro- 
fuse flow  of  saliva,  nausea,  vomiting,  diarrhoea,  constipa- 
tion, indigestion,  ringing  of  the  ears,  feeling  of  fulness 
in  the  head,  headache,  dizziness,  drowsiness,  coma,  con- 
vulsions, or  convulsive  movements  of  muscles. 

In  asylums,  medicines  are  mostly  sent  to  the  wards  in 
single  doses,  each  cup  or  bottle  being  marked  with  the 
name  of  the  patient  for  whom  it  is  intended.  The  tray 
in  which  they  are  carried  should  never  be  set  down  and 
left,  for  a  mischievous  or  suicidal  patient  may  poison 
himself  by  taking  every  thing  he  can  get  hold  of. 

No  patient,  unless  ordered  by  the  physician,  should  be 


SERVICES   OE  ATTENDANTS.  8/ 

allowed  to  keep  his  cup  and  take  his  medicine  at  his 
leisure.  Suicidal  patients  often  ask  to  do  this,  and  then 
save  the  medicine,  until  they  have  enough  to  poison  them- 
selves. Others  will  throw  the  medicine  away.  The  way 
to  administer  medicine  to  the  insane  is  to  give  it  person- 
ally to  the  patient,  and  also  see  that  it  is  swallowed.  It 
is  a  frequent  custom  of  many  patients  to  retain  the  medi- 
cine in  the  mouth,  and,  when  the  attendant  has  left,  to 
spit  it  out. 

It  is  often  very  important  that  patients  should  take  the 
medicine  ordered,  and  every  effort  should  be  made  to  in- 
duce them  to  take  it.  Such  patients  should  be  designated 
by  the  physician.  Night  medicines,  or  those  given  about 
bedtime,  are  usually  of  great  importance.  All  patients 
who  refuse  to  take  their  medicine  should  be  reported  to 
the  physician. 

The  reasons  for  refusing  medicines  are  various  ;  some 
say  they  are  perfectly  well  and  need  no  medical  treatment, 
others  think  the  medicine  injures  them,  that  it  turns  their 
skin  black,  or  poisons  them,  or  that  it  is  wrong  to  take  it, 
or  displeasing  to  God  ;  ideas  much  like  those  that  we 
learned  were  the  causes  for  the  refusal  of  food.  Attend- 
ants are  to  use  every  effort  to  get  patients  to  take  medi- 
cine, and  may  employ  as  much  force  as  they  were 
instructed  to  use  in  giving  food,  but  no  more. 

Patients  should  not  be  deceived  about  medicines,  nor 
told  by  attendants  that  it  is  nothing,  that  it  is  only  a  little 
water,  or  some  nice  drink  that  is  sent  to  them,  nor  should 
an  attempt  be  made  to  give  them,  by  trying  to  disguise 
them  in  food  or  drink,  except  by  the  permission  of  a 
physician.     Patients  should,  on  the  other  hand,   be  told 


88  HOW  TO    CARE  FOR  THE  INSANE. 

that  it  is  medicine,  that  the  doctor  ordered  it  for  them, 
that  it  is  for  their  good  to  take  it,  that  it  is  given  to  help 
them  get  well. 

The  giving  of  medicine  and  food  is  among  the  most 
important  and  frequent  duty  that  an  attendant  is  called 
upon  to  perform,  or  assist  others  in  doing.  Attendants 
must  remember  that  many  medicines  are  injurious  or  even 
poisonous,  if  not  properly  given,  or  if  mixed  with  other 
medicines,  or  if  given  to  the  wrong  patient ;  they  should 
therefore,  never  make  a  mistake,  or,  if  by  carelessness 
they  commit  one,  should  immediately  report  it. 

OpiiLin  and  Some  of  its  Preparations. — Opium  is  a  medi- 
cine that  is  very  frequently  given  to  patients  in  an  asylum. 
The  ordinary  dose  is  one  grain.  Tincture  of  opium^  or 
laudanum^  is  opium  dissolved  in  alcohol.  Ten  minims 
equal  one  grain  of  opium.  Ca7nphorated tincture  of  opium^ 
or  Paregoric,  is  a  weaker  alcoholic  solution,  with  some 
camphor,  and  flavored  with  a  pleasant  aromatic.  One 
half  a  fluid  ounce  equals  a  grain  of  opium.  Morphine  is 
a  white  powder  extracted  from  opium.  An  eighth  of  a 
grain  about  equals  a  grain  of  opium. 

Opium,  in  some  of  its  forms,  is  a  common  household 
remedy.  To  an  adult,  not  more  than  one  grain  should 
be  given  ;  it  should  not  be  repeated  more  than  once,  nor 
less  than  six  hours  after  the  first  dose.  It  would  be  bet- 
ter if  never  given,  except  by  a  physician's  order.  Under 
no  circumstances  should  any  one  but  a  physician  give  it 
to  a  weak  or  old  person,  or  to  a  young  child. 

Opium,  is  given  in  ordinary  doses  to  relieve  pain,  to 
check  diarrhrea  to  relax  spasm  of  muscles,  and  to  produce 
sleep.     The  sleep  from  opium  is  generally  quiet  and  re- 


SERVICES  OF  ATTENDANTS.  89 

freshing,  and  one  from  which  the  patient  can  be  easily 
aroused. 

An  attendant  will  frequently  be  told  when  the  medi- 
cine is  given  and  directed  to  note  and  report  its  effect. 

Opium  Poisoning. — The  taking  of  opium  is  a  frequent 
way  of  committing  suicide  by  persons  outside  of  asylums. 
Sometimes  patients  manage  to  save  their  doses,  or  they 
steal  it  from  the  tray,  or,  if  there  is  some  sent  to  the  ward 
for  repeated  doses,  they  secure  it  through  the  careless- 
ness of  an  attendant,  or  occasionally  it  is  secretly  sent  to 
patients  by  officious  outside  friends, — thus  poisoning  by 
opium  sometimes  occurs  among  asylum  patients. 

The  full  symptoms  of  poisoning  are  profound  coma, 
pupils  contracted  to  pin-points,  and  which  do  not  respond 
to  light  ;  very  slow  respiration,  often  not  more  than  four 
or  six  times  a  minute,  but  heavy  and  labored.  Some- 
times the  effect  of  the  drug  is  but  partial,  the  patient  can 
be  aroused  for  a  moment,  but  falls  to  sleep  again,  or  the 
symptoms  may  be  even  less  pronounced. 

The  treatment  of  opium  poisoning,  before  the  physician 
comes,  consists  in  giving  very  strong  coffee,  or  tea,  an 
emetic,  and  in  trying  to  keep  the  patient  awake  by  walk- 
ing him  about,  or,  if  this  is  not  possible,  to  keep  him  from 
falling  into  deeper  coma,  by  shaking,  calling  loudly  in 
the  ear,  and  striking  and  slapping  the  body  with  wet 
towels. 

Chloral. — This  is  a  white  crystal,  with  a  pungent, 
burning  taste.  It  is  always  dispensed,  dissolved  in  water, 
and  should  be  further  diluted  when  given  to  a  patient. 
The  dose  is  from  ten  to  thirty  grains.  It  is  too  powerful 
a  drug  to  be  given,  except  upon  the  order  of  a  physician. 


90  HOW  TO    CARE  FOR    THE  INSANE. 

Chloral  is  given  to  produce  sleep,  which  is  usually  quiet 
and  natural.     The  effect  lasts  about  four  or  six  hours. 

The  symptoms  of  poisoning  are  not  so  marked  as  to 
make  it  easy  to  know  that  they  are  caused  by  chloral. 
There  is  generally  a  weak  heart  and  pulse,  and  feeble 
respiration,  and  the  patient  is  in  a  deep  sleep,  from 
which  he  may  be  aroused  ;  or  the  coma  may  be  pro- 
found, and  continue  uninterrupted  till  death. 

The  treatment  consists  in  giving  an  emetic,  stimu- 
lants, coffee,  and,  if  necessary,  performing  artificial  res- 
piration. 

Hyoscyamme  and  Hyoscijie. — These  are  extracts,  from 
the  leaves  and  seeds,  of  the  plant  hyoscyamus. 

These  are  very  powerful  medicines,  and  are  never 
given  except  on  the  order  of  a  physician.  They  are  al- 
ways given  in  solution. 

The  action  of  both  is  practically  the  same.  In  ordi- 
nary doses  they  quiet  restlessness,  produce  muscular 
weakness,  flushing  of  the  face,  dryness  of  the  tongue, 
wide  dilatation  of  the  pupils,  and  frequently  cause  sleep. 
These  effects  should  be  noticed  and  reported.  These 
medicines  are  mostly  given  to  patients  who  are  con- 
tinually restless,  violent,  and  sleepless,  and  the  object  is 
to  bring  quiet,  repose,  and  sleep.  Large  doses  may  pro- 
duce coma,  very  heavy  breathing,  and  great  muscular 
weakness  ;  the  pulse  however  is  full  and  strong,  but  if  it 
should  fail,  the  physician  should  be  at  once  sent  for. 

Alcfhol  and  Stimula7its. — It  is  the  alcohol  in  liquors 
that  intoxicate,  and  it  is  that  part,  also,  of  liquor  that 
stimulates  when  given  as  a  medicine.  Whiskey,  brandy, 
and  gin  are  about  one  half  alcohol.     The  dose  is  a  table- 


SERVICES   OF  ATTENDANTS.  9 1 

spoonful,  in  water,  and  not  repeated  oftener  than  two  or 
three  times.  Wines  are  about  one  fifth  alcohol,  beers  and 
cider  about  one  twentieth. 

Liquors  containing  alcohol  are  never  to  be  given  to 
patients  as  a  beverage,  but  always  as  a  medicine,  and, 
except  in  emergencies,  never  without  a  physician's  order. 
Do  not  give  them  in  emergencies,  without  a  good  reason 
for  ^o  doing,  and  not  simply  because  you  feel  you  must  do 
something,  for  in  some  emergencies  they  may  do  a  great 
deal  of  harm,  and  perhaps,  a  fatal  injury. 

Alcohol  is  mostly  given  to  stimulate  the  action  of  the 
heart.  A  stimulant  is  something  "  that  arouses  or  ex- 
cites to  action."  It  is  given  (in  the  doses  just  men- 
tioned) in  accidents,  when  the  heart  is  very  weak,  the 
pulse  almost  or  quite  imperceptible,  the  face  pale  and 
pinched,  and  the  extremities  cold. 

In  continued  sickness,  with  exhaustion,  stimulants  are 
sometimes  left  with  the  attendant  to  give,  with  directions 
about  the  size  of  the  dose  and  its  frequency.  If  it  quiet 
the  patient,  strengthen  the  heart  and  pulse,  it  is  doing 
good  ;  but  if  restlessness  comes  on,  the  face  becomes 
flushed,  or  if  the  pulse  is  made  more  rapid  and  feeble,  it 
is  probably  doing  harm,  and  should  be  discontinued,  and 
the  physician  informed. 

Dry  and  Moist  Heat. — In  applying  heat,  either  dry  or 
moist,  to  the  insane,  care  must  always  be  used  to  protect 
the  skin  from  being  blistered.  This  happens  very  easily 
when  it  is  applied  directly  to  old,  feeble,  paralyzed, 
or  paretic  patients,  and  also  to  those  who  are  too  de- 
mented to  complain  if  they  are  being  burned.  Burns  are 
very  serious  accidents  among  this  class  of  patients,  and 


92  HOW   TO    CARE  FOR    THE  INSANE. 

may,  if  they  extend  over  a  large  surface,  even  though 
not  deep,  heal  with  difficulty,  and  even  prove  fatal. 

Dry  heat  is  applied  by  means  of  rubber  bags  filled 
with  hot  water,  hot-sand  bags,  bricks,  or  soapstones,  and 
by  the  lamp  bath.  Moist  heat  by  hot  baths,  fomenta- 
tions, turpentine  stupes,  and  poultices. 

Hot  Baths  and  Wet  Packing. — Hot  baths  are  some- 
times prescribed  for  patients.  The  water  should  be 
about  loo  degrees  F.,  and,  if  ordered,  slowly  increased 
to  iio°.  The  patient  is  to  be  left  in  as  long  as  directed, 
which  may  be  but  a  few  minutes,  or  half  an  hour,  or 
even  longer.  Sometimes  a  blanket  is  ordered  thrown 
over  the  tub,  the  head  only  being  uncovered. 

When  the  bath  is  being  given,  the  pulse  should  be 
counted  ;  if  it  become  weak  and  rapid,  if  the  face  be- 
come flushed,  and  the  patient  complains  of  dizziness,  or 
if  the  lips  show  venous  congestion,  the  patient  should  be 
at  once  removed,  and,  unless  there  is  immediate  recovery 
from  these  evil  effects,  the  physician  should  be  informed. 

In  giving  a  wet  pack,  the  patient  is  wrapped  in  a 
sheet,  without  any  clothing,  wet  either  in  cold  or  warm 
water,  as  ordered,  and  then  rolled  in  a  blanket,  put  to 
bed,  and  left  in  it  as  long  as  directed. 

These  methods  of  treatment  are  frequently  ordered  by 
physicians  for  patients  who  are  restless,  violent,  and 
sleepless,  with  a  view  of  giving  quiet  and  sleep.  The 
attendant  should  observe  and  report  the  result. 

Application  of  Cold. — The  attendants  are  frequently 
ordered  to  apply  ice  to  some  part  of  the  body,  for  the  pur- 
pose of  producing  local  cold.  The  ice  should  be  broken 
into  small  pieces  and  put  into  a  bladder,  or  rubber  bag, 


SERVICES   OF  ATTENDANTS.  93 

partly  filling  it.     It  remains  sufficiently  cold  until  all  the 
ice  is  melted. 

Another  way  is  to  put  a  piece  of  ice  in  a  sponge  and 
bathe  the  part.  When  cold  cloths  or  compresses  are 
applied,  the  heat  of  the  body  soon  warms  them,  when 
they  become  warm  applications  and  act  as  a  poultice  ; 
they  should  therefore  be  frequently  changed.  In  apply- 
ing moist  dressings  care  must  be  used  not  to  have  any 
leaking  nor  wetting  of  the  bed  or  clothing. 

Hypodermic  Injections. — Morphine,  hyoscyamine,  or 
hyoscine,  in  solution,  are  frequently  injected  under  the 
skin.  The  direction  to  do  this,  and  the  quantity  to  be 
given,  will,  in  every  case,  be  ordered  by  the  physician. 
A  fold  of  the  skin  is  held  between  the  finger  and  thumb, 
while  the  needle  held  in  the  other  hand  is  quickly  pushed 
straight  under  the  skin  to  the  depth  of  about  half  an 
inch.  Care  should  be  used  to  inject  no  air,  and  not  to 
inject  the  contents  of  the  syringe,  into  a  vein. 

Forcible  Feeding  with  the  Stoinach-Tube. — Attendants 
are  frequently  called  upon  to  assist  in  the  forcible  feed- 
ing of  patients,  and  in  some  cases  may  themselves  be 
directed  to  do  it.  The  dangers  of  feeding  are  that  the 
pharynx  may  be  filled  with  fluid,  and  the  patient  choke, 
or  it  may  be  drawn  into  the  lungs,  that  the  wedge  with 
which  the  mouth  is  held  open  may  be  so  loosely  held 
that  in  the  struggle  of  the  patient  the  soft  parts  of  the 
mouth  may  be  injured,  and  occasionally  it  happens  that 
the  mere  pressure  of  the  tube  causes  choking. 

Attendants  should  watch  the  process  of  feeding,  and 
particularly  the  face,  for  symptoms  of  venous  congestion, 
and  report  to  the  physician  any  thing  they  see  that  de- 
notes danger. 


94  HOW   TO    CARE  FOR    THE  INSANE. 

In  preparing  for  feeding,  attendants  must  see  that  the 
food  is  properly  made  ready.  If  any  thing  is  to  be  mixed 
with  milk,  it  should  be  mixed  so  as  to  be  perfectly 
smooth,  without  lumps,  and  so  it  will  run  easily  through 
the  tube.  If  some  concentrated  food  is  used,  it  is  better 
to  put  it  in  a  small  quantity  of  milk,  just  enough  to  make 
it  liquid,  that  it  may  be  given  first.  Medicines  ordered 
for  feeding  are  not  to  be  mixed  with  a  large  quantity  of 
milk,  but  saved,  that  they  may  be  given  directly  from  the 
dispensing  bottle  whenever  the  physician  desires  to  do  so. 

Every  thing  should  be  got  ready  for  feeding  before  the 
physician  arrives.  Upon  a  tray  should  be  all  the  feeding 
apparatus — the  food  and  medicine,  several  spoons,  and 
cups,  and  a  pitcher.  Near  at  hand  should  be  plenty  of 
water,  soap,  and  towels,  and  a  tin  basin.  It  is  very  pro- 
voking to  have  to  v/ait  for  many  things  to  be  brought 
after  the  patient  has  been  got  ready. 

Many  patients  are  easily  fed.  Some  like  it,  but  some 
violently  and  furiously  resist.  Such  patients  should  be 
restrained  to  a  chair  fixed  to  the  floor,  and  the  more 
securely  this  is  done  the  more  easily  can  they  be  fed,  and 
with  less  fatigue  and  danger  of  their  being  injured. 

The  patient's  clothing  should  be  well  protected  from 
being  soiled,  by  towels  about  the  neck,  and  a  basin 
should  always  be  held  under  the  chin  to  catch  falling 
liquids  and  any  thing  vomited.  The  holding  the  head 
and  wedge  is  an  important  matter,  and  is  some  thing  that 
belongs  to  the  attendant  to  do.  The  attendant  stands 
behind  the  patient,  and  holds  the  chin  by  the  right  hand, 
and  with  the  left  firmly  grasps  the  wedge,  which  is  in- 
serted straight  into  the  mouth,  between  the  back  teeth, 


SERVICES  OF  ATTENDANTS.  95 

about  two  or  three  inches.  The  wedge  should  be  grasped 
with  the  palm  upwards,  and  the  little  finger  and  side  of 
the  hand  should  be  pressed  firmly  against  the  chin.  If 
held  in  this  way  there  is  little  danger  that  in  violent 
struggles,  the  wedge  can  be  suddenly  driven  backward 
and  wound  and  tear  the  soft  parts  of  the  mouth.  If  the 
throat  fills  with  fluid,  the  attendant  who  holds  the  head 
should  bend  it  far  forward,  that  it  may,  if  possible,  run 
out  of  the  mouth. 

After  feeding,  patients'  faces  should  be  washed.  They 
should  be  watched  for  some  time  to  see  that  they  do  not 
vomit,  or,  as  is  often  the  case,  that  they  do  not  make 
themselves  vomit. 

There  is  no  special  difference  in  caring  for  a  patient 
fed  with  a  nasal  tube,  except  that  the  wedge  is  not  used. 

If  attendants  are  allowed  to  feed,  they  must  remember 
all  the  dangers,  and  guard  against  them.  In  introducing 
the  tube,  the  forefinger  of  the  right  hand  is  to  be  intro- 
duced at  the  same  time,  and,  as  the  tube  passes  over  the 
tongue  it  is  to  be  turned  downward  by  the  finger  and 
gently  pushed  into  the  oesophagus.  If  there  seem  to  be 
unusual  difficulty  in  so  doing,  severe  and  unusual  strug- 
gling, or  the  slightest  symptom  of  danger,  cease  the  ef- 
fort to  feed,  and  report  to  the  physician 

Of  course  no  attendant  would  undertake  to  feed  any 
patient  unless  ordered  to  do  so  by  the  physician,  which 
order  would  be  given,  if  at  all,  only  after  careful  training 
and  in  cases  easily  fed. 

Nictritive  Enemata. — It  is  often  necessary  to  feed  patients 
by  the  rectum.  This  is  done  by  injecting  food,  to  the 
amount  of  four  or  six  ounces..     Care  should  be  used  to 


96  HOW   TO    CARE  FOR  THE  INSANE. 

inject  no  air.  The  nozzle  of  the  syringe  well  oiled  is  to 
be  gently  introduced,  and  the  fluid  slowly  forced  into  the 
bowel.  The  patient  should  lie  on  the  left  side,  near  the 
edge  of  the  bed,  with  the  knees  well  drawn  up.  If  the 
patient  resist,  he  must  be  placed  upon  the  back,  the  legs 
separated  and  firmly  held.  This  may  require  four  or 
six  attendants,  but  enough  should  always  be  at  hand  to 
thoroughly  and  easily  overcome  the  patient.  Before 
giving  the  first  injection  of  food  the  bowels  should  be 
moved  by  an  injection  of  soap  and  water.  Sometimes 
the  injected  food  escapes  from  the  rectum.  The  patient 
should  be  watched  to  see  if  this  happens.  In  such  a  case  a 
long  tube  can  be  introduced  into  the  rectum,  about  four 
or  six  inches,  and  the  food  injected  through  it.  The  tube 
should  be  well  oiled,  and  introduced  slowly  and  with 
gentle  force. 

Patients  often  thrive  upon  this  way  of  feeding.     The 
character  of  the  food  will  be  ordered  by  the  physician. 


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